Emergency Medicine MCQs

This book is aimed at enhancing your knowledge and improving your critical thinking skills while helping you to identify gaps in your knowledge.


Waruna de Alwis MBBS, FACEM


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  • Waruna de Alwis MBBS, FACEM   
  • 440 Pages   
  • 16 Feb 2015
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    EMERGENCYMEDICINEMCQs read more..

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    EMERGENCYMEDICINEMCQsWARUNA DE ALWISYOLANDE WEINERSydney  Edinburgh  London  New York  Philadelphia  St Louis  Toronto read more..

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    Churchill Livingstoneis an imprint of ElsevierElsevier Australia. ACN 001 002 357(a division of Reed International Books Australia Pty Ltd)Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067This edition © 2012 Elsevier AustraliaISBN 9780729541046This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means read more..

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    CONTENTSvList of Authors and Contributors viiList of Reviewers ixDedication xiPreface xiiiAcknowledgements xvSection 1 Questions 1Chapter 1 Resuscitation 3Chapter 2 Cardiovascular emergencies 11Chapter 3 Respiratory emergencies 18Chapter 4 Neurological and neurosurgical emergencies 24Chapter 5 Endocrine emergencies 28Chapter 6 Gastroenterological emergencies 32Chapter 7 Renal emergencies 37Chapter 8 Haematological and oncological emergencies 41Chapter 9 Infectious diseases 44Chapter 10 read more..

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    viCONTENTSChapter 10 Dermatological emergencies 229Chapter 11 Electrolyte and acid–base disorders 233Chapter 12 Emergency anaesthesia and pain management 241Chapter 13 Trauma and burns 250Chapter 14 Orthopaedic emergencies 267Chapter 15 Surgical emergencies 281Chapter 16 Eye, ENT and dental emergencies 301Chapter 17 Urological emergencies 310Chapter 18 Obstetric and gynaecological emergencies 317Chapter 19 Toxicology and toxinology 330Chapter 20 Environmental emergencies 348Chapter 21 read more..

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    LISTOFAUTHORSANDCONTRIBUTORSviiAuthorsWaruna de Alwis MBBS, FACEMEmergency Medicine Consultant, Director of Emergency Medicine Training, Logan Hospital, Meadowbrook, QLD, AustraliaYolande Weiner MBChB, MMed EM (UCT), FCEM (SA), FACEMEmergency Medicine Consultant, Logan Hospital, Meadowbrook, QLD, AustraliaLIST OF AUTHORS AND CONTRIBUTORSLISTOFAUTHORSANDCONTRIBUTORSviiContributorsAlison Boyle MBBCh, BAO, FACEMEmergency Medicine Consultant, Logan Hospital, Meadowbrook, QueenslandKanchana de Alwis read more..

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    LISTOFREVIEWERSixS Javad Mojtahed Najafi MD, FACEMEmergency Medicine Consultant, St George Hospital, Sydney, New South WalesMary Stevens MBBSEmergency Registrar, St George Hospital, Sydney, New South WalesSarah Bombell MBBSResident Medical Officer, The Canberra Hospital, Australian Capital TerritorySelina Watchorn MBBS, BNursing, BArtsThe Canberra Hospital/Australian National UniversityLIST OF REVIEWERS read more..

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    DEDICATIONxiTo my amazing husband, Michael, for his unlimited support, patience and encouragement.YWTo my wife, Kanchana, for your love, resilience and strength, and to my children, Mahima and Ruveen, for reminding me what’s really important.WDDEDICATION read more..

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    PREFACExiiiThe practice of emergency medicine has expanded over the past two decades in Australasia. The expanding emergency medicine workforce includes both specialists and non-specialists, some of whom are in training positions. The locations of practice range from rural and regional emergency departments (EDs) to tertiary university-affiliated departments. For everybody, a knowledge that covers both the breadth and depth and a wide range of skills are essential to deliver a high standard of read more..

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    ACKNOWLEDGEMENTSxvWe would like to thank all contributors for their invaluable efforts and for the numerous hours they spent preparing the manuscript while attending to increasingly busy clinical practices. We thank Dr Stuart Young, director of emergency medicine at Logan Hospital, and Dr James Collier, co-director of emergency medicine and emergency medicine training at Princess Alexandra Hospital for their support.We also thank Sophie Kaliniecki, publisher, and Neli Bryant, developmental read more..

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    QUESTIONS read more..

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    QUESTIONS3Adult resuscitationYolande Weiner1. Forconfirmingendotrachealtubeplacementfollowingintubationofapatientincardiacarrest,whichONEofthefollowingmethodsisthemostreliable?A.WaveformcapnographyB.Calorimetricend-tidalcarbondioxide(ETCO2)C.OesophagealdetectordeviceD.Pulseoximetry2. read more..

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    4CHAPTER1RESUSCITATIONC.Effectiveexternalcardiaccompressionsprovideanoutputofabout40–50%ofthepre-arrestvalueD.Theinspiredconcentrationofoxygenshouldbereducedto21–60%ashyperoxaemiaisassociatedwithworseneurologicaloutcome9. read more..

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    QUESTIONS731.A42-year-oldfemalepresentstotheEDinshockaftersufferingamassivepulmonaryembolus(PE).Bedsideechocardiographyshowsunequivocalsignsofrightventricular(RV)overload.Regardingthiscase,whichONEofthefollowingstatementsisTRUE?A.Untreated,shehasamortalityofapproximately30%B.FluidresuscitationshouldbeperformedcarefullyasexcessivefluidsmightworsenRVfailureC.ACTpulmonaryangiogrammustbeperformedtoconfirmthediagnosispriortourgentthrombolysisD.Whenthrombolysisareconsidered,tPAshouldbegivenintravenouslyatadoseof0.9mg/kg–10%asabolusdoseover2minutesandtherestasacontinuousinfusionover1hour32.RegardingtheuseoffocusedechocardiographyintheEDtoexaminepericardialeffusionsinacriticallyillpatient,whichONEofthefollowingisTRUE?A.Aprobewithafrequencyof5–10mHzisthemostappropriateB.Aneffusionof<15mmexcludestamponadeC.LVdiastoliccollapseisanearlysignoftamponadeD.AnapicalapproachisusuallypreferredoverthesubxiphoidapproachastheoptimumneedleinsertionsiteforpericardiocentesisPaediatric read more..

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    8CHAPTER1RESUSCITATIONB.CurrentevidencesuggeststhatnewerIOdevices,suchasdrillsandboneinjectionguns,improvetheoutcomeinpaediatricresuscitationC.IObloodcanbeusedreliablyforbiochemical,haematologicalandvenousbloodgasanalysesD.IOaccessisoftenachievedmorerapidlyandsuccessfullythanIVaccessincardiopulmonaryarrestinchildren6. read more..

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    QUESTIONS111. Regardingchestpain,whichONEofthefollowingstatementsisTRUE?A.PainradiatingtotherightarmorshoulderismorepredictiveofmyocardialinfarctionthanpainradiatingtotheleftarmorshoulderB.Burningorindigestionpainisrarelyassociatedwithacutecoronarysyndrome(ACS)C.PainthatisreproduciblebychestwallpalpationexcludesACSD.Unremittingpainofconstantnaturelastingmorethan12hoursislesslikelytobeduetoACS2. read more..

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    12CHAPTER2CARdIOvASCUlAREmERgENCIESC.DiscordanceoftheQRScomplexandSTsegmentorTwaveintheleftbundlebranchblock(LBBB)issuggestiveofmyocardialischaemiaD.STsegmentelevationof1mmin2ormorecontiguouschestleadsmeetsreperfusioncriteria8. read more..

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    18CHAPTER3REsPiRAToRyEmERgEnCiEs1. read more..

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    QUEsTions19C.Pneumoniaseverityindex(PSI)mainlypredictsclinicaldeteriorationinpatientswithCAPD.DeterminingtheseverityofCAPisusefulindistinguishingtypicalfromatypicalaetiology8. read more..

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    20CHAPTER3REsPiRAToRyEmERgEnCiEs16.ItisoftendifficulttoidentifyapneumothoraxonasupineCXRinaventilatedpatient.AllofthefollowingsignsontheCXRsuggestthepresenceofpneumothoraxEXCEPT:A.DeepsulcussignatcostophrenicangleB.Asharpoutlineofthepericardialfat(pericardialfatpadsign)C.OligaemiclungfieldD.Lucencyoverliverandupperabdomennotexplainedbyanabdominalstructure17.Regardingthediagnosisofaspontaneouspneumothoraxinapatientwithseverechronic obstructive pulmonary read more..

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    24CHAPTER4NEuRologiCAlANdNEuRosuRgiCAlEmERgENCiEs1. WhichONEofthefollowingfeaturesisLEASTlikelytobehelpfulinmakingaclinicaldiagnosisofmigraine?A.Agradualonsethemiparaesthesiaprecedingoraccompaniedbyheadachethatlasts<60minutesB.OnsetoflethargyandyawningafewhoursbeforetheonsetofheadacheC.BilateralheadacheD.Externalocularmusclepalsyassociatedwithheadache2. read more..

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    QuEsTioNs2513.Regardingsymptomsofaposteriorcirculationstroke,whichONEofthefollowingisTRUE?A.ApatientmayinfrequentlypresentwithaheadacheB.AmajoralterationofconsciousnessisduetoinvolvementofthemedullaC.SymptomsarenearlyalwaysunilateralD.Homonymoushemianopiaisnotarecognisedsymptom14.Regardingthepredictionofstrokeinapatientwithsymptomsofatransientischemicattack(TIA),whichONEofthefollowingisTRUE?A.Theoverallriskofstrokeat2daysafteraTIAisapproximately4%B.TheABCD2scorepredictslong-termriskofischaemicstrokeC.TheincidenceofcerebralischaemiaisequalinbothpeoplewithdiabetesandthosewithoutD.DiagnosticstudiessuchasaheadCTandMRIdonothelptopredictincreasedshort-termrisk15.Thefollowingconditionsarelikelytoresultinpooroutcomeinischaemicstroke,EXCEPT:A.Hypertensionatthetimeofpresentationwithasystolicpressureover220mmHganddiastolicpressureover120mmHgB.DelayedoxygenadministrationintheEDC.InadequatehydrationintheEDD.Tooaggressivecontrolofbloodpressureatthetimeofpresentation16.Regardingischaemicstrokeinayoungadult,whichONEofthefollowingstatementsisINCORRECT?A.ThereisastrongassociationbetweenischaemicstrokeriskandmigraineepisodeswithauraB.Pregnancy-relatedstrokeisrarebutriskrisesinthelatethirdtrimesteranduntil6weekspostpartumC.CTangiographyhasaveryhighsensitivityindetectingbothcarotidandvertebralarterydissectionD.Unlikeinolderpeople,cardioembolismistheleastimportantcauseofischaemicstrokeinyoungadults17.Regardingcervicalarterydissectioninayoungpatient,whichONEofthefollowingstatementsisTRUE?9. read more..

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    QuEsTioNs27C.DyspnoeaisafeaturewhentherespiratorymusclesareaffectedD.CSFexaminationwilltypicallyshowhighproteincontentandmorethan50×106cells/lthataremainlymononuclearcells29.A10-year-oldchildwithaventriculoperitonealshuntpresentstotheEDwithincreasingheadache,nausea,vomitingandunsteadygaitthathasdevelopedoverthepast48hours.WhichONEofthefollowingstatementsiscorrectregardinghisinitialmanagement?A.Iftheshuntchamberrefillswhencompressed,shuntseriesX-raysarenotindicatedB.ThecombinationofshuntseriesX-raysandaheadCThasahighsensitivityfordetectingshuntmalfunctionC.IfthereisnoevidenceofincreasedintracranialpressureonaheadCT,lumbarpunctureisindicatedtoruleoutshuntinfectionD.Absenceoffeverandmeningismdoesnotreliablyexcludeshuntinfection30.Regardingthediagnosisofbotulismininfancy,whichONEofthefollowingstatementsisTRUE?A.AnascendingparalysismaybeseenintheinfantB.ItisnotassociatedwithanalteredlevelofconsciousnessC.FeverisasignificantclinicalfeatureD.Suckingandfeedingisnotusuallyaffectedintheinfant25.Regardingabsenceseizures,allofthefollowingstatementsaretrueEXCEPT:A.SuddenlossofconsciousnessB.NolossofposturaltoneC.IntactconsciousnessandmentationD.Frequentrecurrentattacksasmanyas100timesdaily26.WhichONEofthefollowingfeaturesofpseudoseizuresisLEASThelpfulindifferentiatingitfromatrueseizure?A.Nohighaniongap(AG)metabolicacidosischeckedat15minutesfromcessationofseizureactivityB.Clonicseizuremovementsofthelimbsthatarealternatingandnon-symmetricalC.AbruptonsetorterminationofseizureactivityD.Lackofpostictalconfusion27.Regardingafirstseizureina36-year-oldmanwithhumanimmunodeficiencyvirus(HIV)infection,allofthefollowingstatementsarecorrectEXCEPT:A.CerebrallymphomaisarecognisedcauseB.MRIisthefirst-lineinvestigationandmayavoidtheneedforlumbarpunctureC.Non-contrastheadCTmaymissasmalllesionduetocerebraltoxoplasmosisD.Themajorityofpatientsdon’thaveanidentifiablecause28.RegardingthediagnosisofGuillain-Barrésyndromeina10-year-oldchild,whichONEofthefollowingstatementsisTRUE?A.DistalmuscularweaknessinthelimbsismoreprevalentthanproximalmuscularweaknessB.AntibodytestingforCampylobacter read more..

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    28CHAPTER5EndoCRinEEmERgEnCiEs1. Regardinglowerlimbexaminationfindingsofapatientwithdiabetes,whichONEofthefollowingstatementsisTRUE?A.Pretibialmyxoedemaisapurplish-pinkplaqueonthefrontoftheshinsassociatedwithtype2diabetesB.Diabeticperipheralneuropathycauseslossoffinetouch,painandtemperaturesensationwithpreservedvibratoryandpositionsenseC.NeuropathicarthropathypresentsasanacutelypainfulswollenjointD.Diabeticfootulcersaremostcommonlyseenunderthemetatarsalheads2. read more..

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    QUEsTions29B.Deepulcerationwith5cmofsurroundingcellulitiswithoutsystemictoxicitymaybeappropriatelymanagedonanoutpatientbasisC.Whenperipheralpulsesarenotpalpable,furthervascularassessmentisnotrequiredbecausethisisafrequentfindinginpeoplewithdiabetesD.Immediatesurgicaldebridementisapriorityforanulcerwith>2cmofsurroundingcellulitis,lymphangitisorpurulentormalodorousdischarge13.Inthediagnosisofalcoholicketoacidosis,whichONEofthefollowingstatementsisTRUE?A.MarkedconfusionoftenaccompaniessevereacidosisB.ElevatedketonebodieslevelsareconfirmedbypositiveKetostixtestingC.PresentationiscommonlyseveraldaysafterceasingalcoholconsumptionD.Bloodglucoseismildlyelevated14.Inthemanagementofalcoholicketoacidosis,whichONEofthefollowingisTRUE?A.IntravenousinsulininfusionisrequiredtosupportresolutionofmetabolicchangesB.IntravenousglucoseresolvesmetabolicdisturbancesmorerapidlythansalinealoneC.RapidintravenoussalinemayinducemetabolicalkalosisD.VitaminB6administrationpreventssubsequentWernicke’sencephalopathy15.Regardingexaminationfindingsinapatientwithadrenalinsufficiency,whichONEofthefollowingstatementsisCORRECT?A.GeneralisedhyperpigmentationoftheskinandmucosalsurfacessuggestssecondaryadrenalinsufficiencyduetopituitaryfailureB.ThepresenceofvitiligosuggestsaprimaryadrenalinsufficiencyC.CushingoidfeaturesmaybefoundinprimaryadrenalinsufficiencyD.Markedhypotensionisausualfindinginsecondaryadrenalinsufficiency16.Regardingthediagnosisofadrenalcrisis,whichONEofthefollowingstatementsisTRUE?A.AdrenalcrisisdoesnotoccurinpatientswithprimaryadrenocorticalinsufficiencyB.Hypotensionnearlyalwaysrespondstofluidresuscitation8. read more..

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    32CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEs1. read more..

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    QUEsTions33C.ItismorecommonlyassociatedwithoralthanparenteralantibioticadministrationD.IntravenousvancomycinisnoteffectiveagainstC. difficile7. A19-year-oldmanpresentswithviolentvomiting,abdominalcrampsandmilddiarrhoea2hoursaftertheconsumptionofleftoverfriedriceandmeat.WhichONEofthefollowingistheMOSTlikelyresponsibleorganism?A.StaphylococcusB.VibrioC.BacilluscereusD.Clostridiumperfringens8. read more..

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    QUESTIONS371. WhichONEofthefollowingstatementsisTRUEregardingclinicalfeaturesthatareMOSTconsistentwiththeassociatedunderlyingcauseofacuterenalfailure(ARF)?A.AcuterenalarteryocclusionisusuallyasymptomaticB.ArthralgiaandrashareuncommonwithacuteinterstitialnephritisC.Papillarynecrosismaypresentwithfever,flankpainandhaematuriaD.Anautoimmuneaetiologyrarelypresentswithfever2. read more..

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    38CHAPTER7RENAlEmERgENCIES8. WhichONEofthefollowingstatementsisTRUEregardingcomplicationsofvascularaccessassociatedwithhaemodialysis?A.Graftsareassociatedwithahighercomplicationratecomparedwithnaturalarteriovenous(AV)fistulasB.BleedingisthemostcommoncomplicationC.ThrombosisofAVfistulawithfailuretoprovideadequateflowfordialysisisanemergencyandrequiresimmediatevascularinterventionD.Infectionusuallypresentswiththeclassicsignsofpain,erythemaandswellingofaninfectedvascularabcess9. read more..

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    QUESTIONS39A.PresenceofperipheraloedemaindicatesdevelopmentofnephroticsyndromeB.ApositivethroatcultureconfirmsthediagnosisC.TheantistreptolysinO(ASO)titeriscommonlyelevatedafterStreptococcalpharyngealandskininfectionsD.TheserumC3levelissignificantlyreducedinthemajorityofpatients,withC4mostoftennormal17.WhichONEofthefollowingfeaturesisNOTconsistentwithnephroticsyndrome?A.ARFisrareinprimarynephroticsyndromeB.Thecharacteristicsofnephroticsyndromeincludeoedema,hypoalbuminaemia,proteinuriaandhyperlipidaemiaC.MicroscopichaematuriaistypicallyabsentanddistinguishesthediseasefromglomerulonephritisD.Nephroticchildrenareathighriskofthromboemboliccomplications18.WhichONEofthefollowingstatementsisTRUEregardinghaematuria?A.HaematuriaassociatedwithpainduringurinationisoftenduetoaneoplasticcauseB.GrossmacroscopichaematuriaismoreoftenassociatedwitharenalthanpostrenalcauseC.Theincidenceofunderlyingdiseaseinpatientswhodevelophaematuriawhileonanticoagulantsisapproximately10%D.Mostpatientsagedover40yearswithafirstepisodeofasymptomaticmicroscopichaematuriashouldbefurtherinvestigated19.WhichONEofthefollowingisINCORRECTregardingprostatitis?A.Gram-negativebacillisuchasEscherichia read more..

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    QUESTIONS411. A31-year-oldmalerequiresanemergencybloodtransfusion.WhichONEofthefollowingstatementsisTRUE?A.Onegativebloodmustbegivenifcross-matchingcan’tbeperformedB.OpositivebloodcansafelybegiveninthisscenarioC.Uncross-matchedOpositivebloodshouldnotbegiveninthiscaseduetothehigherriskofacutehaemolyticreactioncomparedwithOnegativebloodD.Type-specificbloodtakesapproximately20minutes2. read more..

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    42CHAPTER8HAEmATOlOgICAlANdONCOlOgICAlEmERgENCIESA.Tenecteplase,athirdgenerationfibrinolytic,isapprovedfortreatmentofacuteischaemicstrokeB.Intravenousalteplase(rtPA)isgivenasaweight-baseddoseviaaninfusionover60minutesC.AspirinshouldbegivenimmediatelyonceanintracranialbleedisexcludedonCTD.Afterthrombolysis,patientsshouldreceiveheparinanticoagulationatareduceddose8. read more..

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    44CHAPTER9InfECTIousDIsEAsEs1. read more..

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    QuEsTIons47A.Airborne,dropletandcontactprecautionsshouldbeusedinplaceofstandardprecautionsB.Handwashingwithsoapandwateriseffectiveinpreventingspreadofinfectionofmultidrug-resistantorganismsC.PatientssuspectedofhavingpertussisrequireisolationinanegativepressureroomwhileintheEDD.Policiesregardingprotectionofstafffrominfectiousagentsshouldadvocatetheuseofequipmentthatlowerstheriskofpercutaneousexposuretoinfection19.AnEDresidentcomestoaskyouradviceonwhatantimicrobialtreatmenttostartintheEDforapatientwithafebrileillnessofunknownsource.Thepatient,a62-year-oldwomanonsulfasalazineforrheumatoidarthritis,hasasystemicinflammatoryresponse.WhichONEofthefollowingisCORRECT?A.Ifthispatienthadchronickidneydisease,thefirstdoseofgentamicinshouldbereducedB.Ifprescribingafluoroquinoloneantibioticforthispatient,thereisnoneedtoreviewherregularmedications,whichincludeacalcium-containingantacidC.Ifthepatienthadhadarecentsignificantpseudomonalinfection,ceftazidimewouldbeabetterchoiceofempiricantibioticthanceftriaxoneD.Ifthesourceofinfectionwasthoughttobeadeeptissueinfectionfroma2-week-oldwoundsustainedinshallowmarinewater,benzylpenicillinwouldbesufficientcover20.A17-year-oldmalepresentstotheEDwitha6-hourhistoryofvomitingandprofusediarrhoeaandblurredvision.Hehasnopastmedicalhistory,medicationsorallergiesandliveswithtwoothercollegestudents,neitherofwhomhavesymptoms.Onexaminationheismildlydehydrated;heisunabletotolerateoralfluidsduetodifficultyinswallowing,andhispoweris3/5intheupperlimbsand4/5inthelowerlimbs.Whatisthemostlikelycausativeorganism?A.Botulinum read more..

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    QUESTIONS491. Targetortarget-likelesionsareseeninallofthefollowingconditionsEXCEPT:A.ErythemamultiformeB.Toxicepidermalnecrolysis(TEN)C.Stevens-Johnsonsyndrome(SJS)D.Pyodermagangrenosum2. WhichONEofthefollowingstatementsisTRUEregardingSJSandtoxicepidermalnecrolysis?A.IntheseconditionsmorethanonemucousmembranesurfaceisaffectedB.Theepidermaldetachmentinvolvesmorethan50%ofthebodysurfaceareaC.BacterialinfectionsaretheusualcauseofbothconditionsD.Eyesaresparedinbothconditions3. read more..

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    50CHAPTER10DERmATOlOgICAlEmERgENCIES10.Regardingherpessimplexinfectionsinchildren,whichONEofthefollowingstatementsisINCORRECT?A.Herpessimplexvirus(HSV)type1iscommonlyinvolvedinskininfectionsofthefaceB.HerpeticwhitlowisoftenmisdiagnosedasbacterialinfectionC.EczemaherpeticumisthedisseminatedherpessimplexinfectionassociatedwithatopiceczemaD.Typicalherpesvesiclescanoftenbeseenineczemaherpeticum read more..

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    QUESTIONS511. WhichONEofthefollowingisacauseforpseudohyponatraemia?A.HyperglycaemiaB.Syndromeofinappropriateantidiuretichormone(SIADH)C.HyperlipidaemiaD.Livercirrhosis2. WhichONEofthefollowingisNOToneofthecriteriarequiredinmakingadiagnosisofSIADH?A.HypotonicityB.Urinaryosmolality>plasmaosmolalityC.NormovolaemiaD.Urinary[Na+]<20mmol/L3. read more..

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    52CHAPTER11ElECTROlyTEANdACId–BASEdISORdERSWhichONEofthefollowingdrugs/poisonswouldNOTtypicallyexplaintheaboveresults?A.ParacetamolB.EthanolC.CyanideD.Acetone10.WhichONEofthefollowingisacauseofsalineunresponsivemetabolicalkalosis?A.ThiazidediureticuseB.ProtractedvomitingC.PrimaryhyperaldosteronismD.Cysticfibrosis11.WhichONEofthefollowingconditionsisassociatedwithhypokalaemia?A.Beta-blockersB.MetabolicalkalosisC.AddisoniancrisisD.Digoxinintoxication12.A48-year-oldalcoholicmanpresentstotheEDafteranepisodeofsyncope.AnECGisperformedthatshowsaQTcof523ms.WhichONEofthefollowingelectrolyteimbalanceswouldLEASTlikelybeacauseforhisprolongedQTc?A.HypomagnesaemiasecondarytonutritionaldeficiencyB.HypokalaemiasecondarytovomitingC.HyponatraemiasecondarytolivercirrhosisD.Hypocalcaemiasecondarytoincreasedcalciumexcretion13.WhichONEofthefollowingECGfindingswouldyouLEASTexpecttoseeinapatientwithhyperkalaemia?A.Tall,symmetricalpeakedTwavesB.ShortenedPRintervalC.ShortenedQTintervalD.WideningofQRScomplex14.WhichONEofthefollowingisNOTapotentialcomplicationinthetreatmentofmetabolicacidosiswithsodiumbicarbonate?A.DehydrationB.OvershootalkalosisC.Cerebrospinalfluid(CSF)acidosisD.Hypercapnoeaandrespiratoryfailure15.WhichONEofthefollowingconditionsisNOTanindicationfortheuseofbicarbonatetherapyinmetabolicacidosis?A.TricyclicantidepressantoverdoseB.SeverehyperchloraemicacidaemiaC.DiabeticketoacidosisD.Hyperkalaemiawithcardiactoxicity16.An8-week-oldboyisbroughttotheEDwitha3-dayhistoryofvomiting.Hisvenousbloodgasshows:• read more..

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    QUESTIONS5318.WhichONEofthefollowingbloodgaspictureswouldyouexpecttoseeina6-year-oldboybeingtreatedforacutelife-threateningasthma?A.pH7.21,CO2=76,HCO3=27,K+3.3B.pH7.21,CO2=76,HCO3=27,K+5.3C.pH7.55,CO2=26,HCO3=21,K+5.3D.pH7.55,CO2=26,HCO3=35,K+3.319.A48-year-oldmanpresentstotheEDwitharightmiddlelobepneumonia.Hisarterialbloodgasonroomairtakenonarrivalisasfollows:• pH7.55(7.35–7.45)• PCO218mmol/L(35–45)• PO270mmol/L(80–100)• read more..

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    54CHAPTER12EmERgEnCyAnAEsTHEsiAAndPAinmAnAgEmEnT1. WhichONEofthefollowingtechniquesprovidesthebestvisualisationofthevocalcordsduringrapidsequenceintubation(RSI)?A.Backwards-upwards-rightwardspressureonthyroidcartilage(BURPmanoeuvre)B.BimanuallaryngoscopyC.RetractionoftherightsideofthemouthlaterallybyanassistantD.Sellick’smanoeuvre2. read more..

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    QUEsTiOns559. read more..

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    QUESTIONS571. Regardinganatomicalandphysiologicalfeaturesinchildrenthatshouldbeconsideredinthemanagementoftrauma,whichONEofthefollowingisTRUE?A.RibscontributemosttothechestexpansionduringbreathingB.ThelarynxsitsmoreanteriorlyandinferiorlythaninadultsC.ThetidalvolumeperkilogramofbodyweightincreasesthroughtoadulthoodD.Childrenhaveahighercirculatingbloodvolumeperkilogramofbodyweightthanadults2. read more..

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    64CHAPTER14ORTHOPAEdiCEmERgEnCiEs1. RegardingSalter-HarristypeIgrowthplateinjuries,whichONEofthefollowingstatementsisFALSE?A.TheepiphysisseparatescompletelyfromthemetaphysisB.ThereistendernessoverthegrowthplateonexaminationbutnoradiologicalabnormalityC.AdisplacedepiphysisintypeIinjuryisusuallydifficulttoreduceD.TypeIinjuriesarecausedbyshearingandavulsionforcescomparedwithtypeVinjuries,whicharecausedbyaxialcompression2. read more..

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    QUEsTiOns65A.ItmaybecausedbyminimaltraumaoratwistinginjuryduringordinaryplayB.Themajorityoffemurfracturesinchildren<1yearofagearesecondarytoaccidentalinjuryC.ShockiscommoninisolatedfemurfracturesinchildrenD.Intoddlers(1–2yearolds)spiralfracturesarecommon9. read more..

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    68CHAPTER14ORTHOPAEdiCEmERgEnCiEsC.AlateralmalleolarfractureatorbelowtheanklejointlinearemorelikelytocausedistaltibiofibularsyndesmosisdisruptionthanfracturesabovethejointlineD.Bimalleolarfracturesareconsideredstableinjuries33.WhichONEofthefollowingfeaturesisLEASTlikelytobeassociatedwithasignificantLisfranc’sinjury?A.AssociatedcompartmentsyndromeB.TarsalandmetatarsalfracturesC.IncreasedfootarchheightD.DisruptionoftheLisfranc’sligament34.Regardingunilateralfacetjointdislocationinthecervicalspine,whichONEofthefollowingstatementsisTRUE?A.AsappearsonthelateralX-ray,thevertebralbodyisdisplacedanteriorlyformorethan50%ofitswidthB.AssociatedspinalcordinjuryiscommonC.TheusualmechanismishyperextensionofthecervicalspineD.Thisisastableinjurywhenthereisnoassociatedfracturepresent35.AnadultmalewhohadacervicalspineinjurywithasignificantmechanismpresentstotheEDcomplainingofseverepainandlimitedrangeofmotion.FractureanddislocationhavebeenexcludedwithaCTscan.Regardingisolated read more..

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    QUEsTiOns69C.Initialconservativemanagementwithintravenousantibioticsfor24hoursshouldbeattemptedD.PainduringpassiveextensionofthePIPandDIPjointsindicatesflexorsheathtenosynovitis40.Regardinglikelyinfectingorganismsinvolvedincausingacuteosteomyelitisinadults,allofthefollowingstatementsaretrueEXCEPT:A.Polymicrobialinfections,whichincludeStaphylococcus aureus, Staphylococcus pyogenes,coliformsandanaerobescauseoeteomyelitisinpoorlycontrolleddiabeticsB.Staphylococcus read more..

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    70CHAPTER15SuRgiCAlEmERgEnCiES1. Regardingappendicitis,whichONEofthefollowingstatementsismostCORRECT?A.PainmaybelocalisedtotheflankorrightupperquadrantB.ObturatorsignispositivewhenpainiselicitedonexternalrotationofthehipC.ApatientwithaMANTRELSscoreof<7shouldbereferredforsurgeryD.Theperforationrateishighbetweentheagesof5and60years2. read more..

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    QuESTiOnS71B.IVfluids,nilbymouth,nasogastrictubeinsertionreferralforlaparotomyC.IVfluids,nilbymouth,nasogastrictubeinsertion,sigmoidoscopyandinsertionofarectaltubeD.IVfluids,nilbymouth,nasogastrictubeinsertion,contrastenema8. read more..

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    QuESTiOnS73B.HaveurgentinvestigationwithDopplerultrasoundfollowedbytreatmentwiththrombolysisprovidingtherearenocontraindicationsC.HaveurgentinvestigationwithDopplerultrasoundfollowedbytreatmentwiththerapeuticsubcutaneouslowmolecularweightheparinD.Havetheankle-brachialindexchecked,ECG,CXR,angiographyandbereferredtotheoutpatientclinicforfollowup24.Apatientwithahistoryofintravenousdrugusepresentswithanacutelypainfulhand.Itiscool,paleandmottled.Radialandulnarpulsesarepresent.Thesecond–thirdfingertipsareduskyincolourandthereispainonbothpassiveandactivewristmovement.Otherthananelevatedcreatinekinaselevelof3000IU/L(35–145IU/Lnormalrange),laboratoryinvestigationsareallwithinthenormalrange.WhatistheMOSTlikelydiagnosis?A.Raynaud’sdiseaseB.InadvertentintraarterialinjectionofadrugC.AcuteischaemiclimbD.Deepvenousthrombosis(DVT)oftheupperlimb25.Apatientwithahistoryofintravenousdrugusepresentswithanacutelypainfulhand.Itiscool,paleandmottled.Radialandulnarpulsesarepresent.Thesecond–thirdfingertipsareduskyincolourandthereispainonbothpassiveandactivewristmovement.Otherthananelevatedcreatinekinaselevelof3000IU/L(35–145IU/Lnormalrange),laboratoryinvestigationsareallwithinthenormalrange.WhatistheMOSTappropriatenextstep?A.RequestaDopplerultrasoundscan(USS)oftheupperlimbandcommenceheparininfusionB.Rest,elevation,compressionbandageandanalgesia.CommencesubcutaneouslowmolecularweightheparinandwarfarinC.MeasurecompartmentalpressuresandconsiderfasciotomyD.Analgesia,heparininfusion,DopplerUSS,measurecompartmentalpressures,considerfasciotomy26.WhichONEofthefollowingstatementsaboutaorticdissectionisTRUE?A.DistaldissectionsrequiresurgicalinterventionB.CXRisaspecificinvestigationC.NeurologicalcomplicationsoccurfrequentlyD.Thesiteofdissectionrarelyoccursatasitewhereatherosclerosisispresent27.WhichONEofthefollowingstatementsabouthaemorrhoidsismostCORRECT?A.PortalhypertensionisacauseofhaemorrhoidsB.Theycanpresentwithpruritisani,mucoiddischargeandprolapseC.InternalhaemorrhoidsoriginateabovethedentatelineandhavesomaticinnervationD.ThrombosedexternalhaemorrhoidscanbeincisedanddrainedintheED28.Regardingpilonidalsinus,whichONEofthefollowingstatementsisTRUE?A.TheyareseenmorecommonlyinfemalesthanmalesB.Recurrenceiscommonandcanbeseeninupto40%ofpatientsC.TheyaretreatedprimarilywithantibioticsD.Theyarefrequentlyseenintheover-50agegroup29.Regardinginfectionofthebreast,whichONEofthefollowingstatementsisthemostCORRECT?A.Breastinfectionsoccurinoneofevery10lactatingwomenB.Innon-lactatingwomenStaphylococcus read more..

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    76CHAPTER16EyE,EnTAnddEnTAlEmERgEnCiEs1. read more..

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    QUEsTiOns7925.Regardingtonguelacerations,whichONEofthefollowingstatementsisFALSE?A.AlingualblockorlocalanaestheticinfiltrationarethepreferredanaestheticchoicesB.AlargegapinglacerationifnotrepairedresultsinagroovedorabifidtongueC.LignocainewithadrenalineshouldnotbeusedforlocalanaesthesiaandtoachievehaemostasisD.Adeeplacerationinvolvingthemusclecanbesuturedwithdeepstitchesthatpenetrateboththemucosaandthemuscle read more..

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    80CHAPTER17URologiCAlEmERgEnCiEs1. WhichONEofthefollowingregardingpercutaneoussuprapubiccatheterisation(SPC)isFALSE?A.HistoryofpreviouslowerabdominalsurgeryorirradiationisacontraindicationtoSPCinsertionB.Recognisedcomplicationsincludeextraperitonealextravasation,haematuriaandinjurytothebowelC.Indicationsincludetraumatotheurethra,phimosiswithurinaryretentionandpelvictraumaD.Itislesslikelytocausebacteriuriathanurethralcatheterisation2. read more..

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    82CHAPTER18ObsTETRiCAndGynAECOlOGiCAlEmERGEnCiEs1. read more..

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    QUEsTiOns83B.Administrationof625IUissufficientafterallsensitisingeventsC.TheAustralianRhimmunoglobincanbeadministeredviatheintramuscular(IM)orIVrouteD.IfaKleihauertestisperformed,maternalvenousbloodshouldbecollectedinanEDTA®tube8. read more..

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    86CHAPTER19ToxiCologyAndToxinologyToxicologyDeepak Doshi and Waruna de Alwis1. AllofthefollowingaretechniquesofextracorporealeliminationoftoxinsEXCEPT:A.Multipledoseactivatedcharcoal(MDAC)B.ExchangetransfusionC.Continuousveno-venoushaemofiltration(CVVH)D.Haemoperfusion2. HaemodialysisisLEASTlikelytobeusefulinwhichONEofthefollowingtoxicities?A.CarbamazepinetoxicityB.SeverelacticacidosissecondarytometformintoxicityC.EthyleneglycoltoxicityD.Systemicirontoxicity3. read more..

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    QUESTionS9145.Funnel-webspiderbiteispotentiallylethal.Allofthefollowingarefeaturesoffunnel-webspiderbiteEXCEPT:A.LocalerythemaandswellingB.VisiblefangmarksC.PainatthesiteofthebiteD.Sweating46.Regardingboxjellyfish(Chironex read more..

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    92CHAPTER20EnviRonmEnTAlEmERgEnCiEs1. Regardingthemanagementofheatstroke,whichONEofthefollowingisTRUE?A.Theendpointofcoolingtechniquesisarectaltemperatureof36–38°CB.BenzodiazepineisanappropriatechoiceofdrugtosuppressshiveringassociatedwithsomecoolingtechniquesC.TemperatureshouldgraduallybereducedoverafewhourstoreduceshiveringD.Evaporativecoolingwithice-coldwateristhepreferredexternalcoolingtechnique2. read more..

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    QUEsTions938. Regardinginjuriescausedbylightning,whichONEofthefollowingisTRUE?A.Keraunoparalysisisalightning-inducedlimbparalysisoftransientnatureB.ThemostcommoninitialrhythmincardiacarrestisventricularfibrillationC.PathognomonicLichtenbergfiguresontheskinareusuallyassociatedwithdeeptissueinjuryD.Fixed,dilatedpupilsseenafterresuscitationwithreturnofspontaneouscirculationalwayscarryapoorprognosis9. read more..

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    94CHAPTER21PsyCHiATRiCEmERgEnCiEs1. Regardingmentalstateexamination(MSE),whichONEofthefollowingstatementsisINCORRECT?A.DiagnosisisanimportantoutcomeofMSEB.MSEstartsoncommencementoftheinterviewwiththepatientC.CommandhallucinationsinapatientindicateseriousillnessD.Restrictedaffectiscommonlyfoundinschizophrenia2. read more..

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    QUEsTiOns95D.Liaisewiththehospital’semergencypsychiatryteamandorganiseashortadmissiontothepsychiatrywardtohelpherinhersituationalcrisis7. Borderlinepersonalitydisorder(BPD)canpresentwithothercomorbidpsychiatricconditions.AllofthefollowingarecommonpresentationstotheEDEXCEPT:A.MooddisordersB.AlcoholdependenceC.AnorexianervosaD.Paranoidschizophrenia8. read more..

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    QUESTIONS971. Regardingnormalphysiologicalchangesintheneonate,whichONEofthefollowingisINCORRECT?A.Aneonatewillloseapproximately10%ofitsbirthweightinthefirstweekoflifeB.Newbornsgainapproximately30gofweightperdayforthefirst3monthsoflifeC.Ifexclusivelybreastfed,anormalstoolingpatternwouldrangefromonestoolperdaytooneperweekD.Aneonatalheartrateof200bpmisindicativeofseriouspathology2. read more..

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    98CHAPTER22PAEdIATRICEmERgENCIES8. read more..

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    QUESTIONS99B.Theincidenceofmeningococcaldiseaseis35%inthissettingC.ThischildshouldbeinvestigatedimmediatelywithWCC,BCandcoagulationstudiesD.Allchildrenwithpetechiaemustreceiveceftriaxone15.A2-year-oldchildpresentswithafeverof39°C.Regardingtheclinicalapproachtothispatient,whichONEofthefollowingisCORRECT?A.IdentifyingasourceforthefeveristhefirstpriorityduringassessmentB.ThefirstpriorityinthissettingistoexcludesignsofovertsepticshockC.Ifsignsofshockarepresent,rapidinfusionofcrystalloiduptoatotalof20mL/kgshouldbecommenced,followedbyinitiationofinotropicsupportD.Ifsignsofhypoperfusionarepresent,afullsepticwork-upshouldbeperformed,includingfullbloodcount(FBC),BC,CXR,throatswab,urineandLP16.A12-month-oldboypresentstotheEDwithageneralisedrashandfeverfor6days.Hehasbeentreatedfor‘tonsillitis’byhisgeneralpractitioner(GP)withamoxicillinsyrupfor3dayswithnoimprovement.Examinationrevealsatemperatureof39°C,dehydration,dry,fissuredlipsandinjectedpharynx.Apinkmorbilliformrashispresentonthetrunk.Amildconjunctivitiswithoutexudateispresent.Urinemicroscopyshows100leucocytesandnobacteria.WhichONEofthefollowingisthebestanswer?A.MeaslesisthemostlikelydiagnosisB.ScarletfeveristhemostlikelycauseoftheillnessC.AntistreptolysinOtitreislikelytoberaisedD.Treatmentwithintravenousimmunoglobulinislikelytoberequired17.A2-year-oldgirlpresentswithfever,sorethroatandcoryzalillnessfor5days.Shedevelopedamaculopapularpinkrashonday2ofherillnessaswellas‘pinkeyes’.Sheappearsmiserableonexaminationwithatemperatureof40°C,bilateralconjunctivitiswithexudate,phayngealinjectionanddry,fissuredlips.Shehaspainfulcervicaladenopathyandaprofusepinkmorbilliformrashonhertrunk.WhichONEofthefollowingisINCORRECT?A.AdenovirusisapotentialinfectiveaetiologyforthispresentationB.Feverlasting5daysormoreshouldbeinvestigatedfurtherC.Othercausesofinfectiousmononucleosis(IM)needtobeexcludedD.Kawasakidisease(KD)isexcludedifanalternativeviralcauseisfoundonPCRtesting18.Regardingtypicalandincomplete(atypical)KD,whichONEofthefollowingisthebestoption?A.Childrenaged1–4yearshaveahigherriskofpresentingwithincompleteKDB.CervicaladenopathyisthecriteriamostcommonlyabsentinbothtypicalandincompleteKDC.MucousmembranechangesweretheleastconsistentfindingacrossthetypicalandincompleteversionsofthisillnessD.ItisimportantnottooverdiagnoseincompleteKDbecausetheriskoftreatmentwithaspirinishighinyoungchildren19.RegardingUTIinchildren,whichONEofthefollowingisCORRECT?A.AUTIisconfirmedonasuprapubicbladderaspiratesampleonlyifapuregrowthof>1000CFUisgrownoncultureB.Anegative‘urinarybag’sampleondipsticktestingisasensitivetestforexcludingaUTIC.ChildrenwithaconfirmedUTIwillneedamicturatingcystourethrogram(MCUG)toexcludeuretericrefluxD.Childrenunder4yearswithaconfirmedfirstUTIshouldhavearenalultrasoundtoexcludeobstructiveuropathy20.Regardingmeningitisinchildren,whichONEofthefollowingisCORRECT?A.AnormalbloodWCCreliablyexcludesbacterialmeningitisB.ChildrenwithIgGsubclassdeficiencyareatincreasedriskofinfectionwithH. read more..

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    QUESTIONS10341.Regardingan18-month-oldchildpresentingtotheEDwithrecurrentepisodesofmildwheezingandnohistoryofatopy,whichONEofthefollowingistheBESTanswer?A.AtrialofsalbutamolwillprovethatthechildhasasthmaB.Ifthereisaresponsetosalbutamoltherapy,steroidsareindicatedinthissituationC.ThelikelydiagnosisisatypicalpneumoniaorviralpneumoniacausingwheezeD.Thischildhastransientwheezingofinfancy42.An8-year-oldgirlhasahistoryofintermittentwheezingepisodesrespondingtosalbutamolaswellasadrycoughonmostnightsoftheweek.Hergrowthanddevelopmentisnormal.WhichONEofthefollowingisthemostappropriateanswer?A.CysticfibrosisneedstobeexcludedbygeneticandsweatchloridetestingB.ThiscouldrepresentchronicsuppurativelungdiseaseandsputumcultureisindicatedC.SheneedstocommenceonacourseofinhaledfluticasoneproprionateD.Sheneedstocommenceonacourseofcombinedsalmeterolandfluticasonetherapy43.Afullyimmunized2-year-oldchildpresentstotheEDwithachroniccoughfor5weeksfollowingacoryzalillness.Thechildappearswellandclinicalexaminationisunremarkable.WhichONEofthefollowingistheBESTanswer?A.CoughvariantasthmaisalikelycauseforthesymptomsandacourseofinhaledsteroidisindicatedB.ThischildshouldbeinvestigatedforcysticfibrosisC.ACXRisindicatedbecausepneumoniaisalikelydiagnosisD.Anasopharyngealaspirateisausefultestinthisscenario44.Regardingpneumoniainchildren,whichONEofthefollowingisINCORRECT?A.Bacterialpneumoniausuallyhasasuddenonsetwithfever>39°C,tachypnoeaandcoughB.Mycoplasmausuallypresentswithgradualinsidiouspneumoniasymptomsincludingfever,malaiseandcoryzaC.Staphylococcus read more..

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    QUESTIONS1051. Regardingdisasterplanning,whichONEofthefollowingstatementsisTRUE?A.TheresponsibilityfordisasterplanninginAustralialieswiththelocalgovernmentofeachregionB.Inanationallyagreedstandardofspecifichazards,CodeBlackreferstoapersonalinjurythreatC.Amajorincidentmaybedefinedasanincidentresultinginharmtomorethan100peopleD.Planningprocessesaddressfourelements–clinical,nursing,pathologyservicesandportering2. read more..

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    106CHAPTER23DISASTERMANAgEMENTB.PneumonicplagueduetoYersinia pestisrespondsrapidlytooralpenicillinC.SmallpoxclassicallypresentswithacentripetaldensevesicularrashD.Botulismtoxicityinducesalethalspasticparalysisoftherespiratorymuscles8. read more..

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    QUESTIONS1071. RegardingtheAustralasianCollegeforEmergencyMedicine(ACEM)guidelinesonemergencydepartment(ED)layoutdesign,whichONEofthefollowingstatementsisINCORRECT?A.Thetotalnumberoftreatmentareasshouldbeatleast1per1,100yearlyadmissionsB.PaediatricclinicalspacesshouldbeaslargeasifnotlargerthanthoseforadultsC.AmbulatoryandambulanceentrancesareideallycolocatedforconsistencyoftriageD.Atleastonehalfofthetotalnumberoftreatmentareasshouldhavephysiologicalmonitoring2. read more..

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    108CHAPTER24EdMANAgEMENTANdMEdICOlEgAlISSUESD.Burnoutismostcommonlyseeninfemaleemergencycliniciansintheinitialyearsoffirstconsultantposts8. RegardingcomplaintmanagementintheED,whichONEofthefollowingstatementsisTRUE?A.ComplaintsareoftenmosteffectivelymanagedinpersonatthetimeoftheproblemB.ComplaintsmostcommonlyariseasaresultofpoormedicalperformanceC.ApologiesshouldbeavoidedbecausetheyconstituteanadmissionofnegligenceD.MostEDcomplaintsarerelatedtoissuesbeyonddepartmentalcontrol9. read more..

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    ANSWERS115Adult resuscitation1. Answer: AThe detection of ETCO2 is widely accepted as the most reliable method for verifying tracheal intubation. However, the efficacy of this method can be hindered in situations where insufficient CO2 is exhaled because of reduced pulmonary blood flow, such as during cardiac arrest, which has led to the assumption that the oesophageal detector device (EDD) might be more accurate in cardiac arrest situations. However, conflicting results have been reported read more..

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    116CHAPTER1RESuSCiTATioNBoth volume- and pressure-controlled ventilation can be used in ventilating asthmatics, but volume-controlled ventilation is usually preferred. Pressure-controlled ventilation entails the risk of variable tidal volume (due to fluctuating high airway resistance and intrinsic PEEP), with sometimes unacceptably low alveolar ventilation.actionGoTo:141,11–137. Answer: DThe role of NIV in ARDS is still uncertain and not routinely recommended, although it may be considered read more..

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    ANSWERS117while the defibrillator is charged if using pads. This approach appears to be safe and it minimises interruption to chest compressions. CPR should be restarted immediately after delivering a shock, irrespective of apparent electrical success. A pulse check should not be performed. The likelihood of developing a rhythm associated with an output is extremely small in the first minute after a shock has been delivered.It is now recommended that a single shock strategy be used in patients read more..

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    118CHAPTER1RESuSCiTATioNpressor in cardiac arrest and the use of either is actionGoTo:142,acceptable.19,2015. Answer: CCurrent resuscitation guidelines acknowledge that research in the area of maternal resuscitation is lacking. Despite this, it is recommended that a perimortem caesarean should be considered early in maternal cardiac arrest if the fetus is of viable age. Prognosis for the intact survival of infant is best if delivery occurs within 5 minutes of maternal arrest; however, if the read more..

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    ANSWERS119recommends that comatose adults with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32–34 °C for 12–24 hours and that therapeutic hypothermia should be considered in comatose survivors of an OHCA after all rhythms or after an in-hospital cardiac arrest. This can be safely initiated with a rapid infusion of 4°C normal saline at 30 mL/kg over 2 hours.actionGoTo:142,19,2419. Answer: BRegarding prognostication after cardiac arrest:• In adult patients comatose read more..

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    120CHAPTER1RESuSCiTATioN21. Answer: DAdrenaline can cause hyperlactataemia and its use should be taken into account when interpreting blood lactate measurements.Lactic acidosis is defined by convention as the combination of an increased blood lactate concentration >5 mmol/L and acidaemia (arterial blood pH < 7.35), whereas hyperlactaemia is defined as a blood lactate level ≥2 mmol/L. Critically ill patients with a lactic acidosis usually have a high mortality, and a blood lactate level read more..

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    ANSWERS121reversible and can be used in the spontaneously breathing patient. The best way to perform a PLR manoeuvre is to elevate the lower limbs to 45° while at the same time placing the patient in the supine from a 45° semirecumbent position. Starting the PLR manoeuvre from a total horizontal position may induce an insufficient venous blood shift to elevate significantly cardiac preload. By contrast, starting PLR from a semirecumbent position induces a larger increase in cardiac preload read more..

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    122CHAPTER1RESuSCiTATioNeffects. This makes it a useful agent for managing hypotension in patients with severe aortic stenosis or hypertrophic cardiomyopathy.Although administration of dobutamine via the central route is preferred, it can safely be infused via the peripheral route. Infusion of adrenaline and noradrenaline should be restricted to the central route.Due to the absence of β2 effects, noradrenaline causes no or minimal vasodilation in skeletal muscle vasculature. Therefore, it read more..

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    ANSWERS123results from the transfusion of white blood cell antibodies (leukoagglutinins) that react with the recipient’s leucocytes. Clinically, TRALI is indistinguishable from ARDS. The patient has acute respiratory distress, diffuse bilateral alveolar and interstitial infiltrates on chest X-ray, and varying degree of hypoxaemia. The overall prognosis is better than what would be expected with many other causes of actionGoTo:142,ALI.4431. Answer: BFluid resuscitation should not be withheld in read more..

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    124CHAPTER1RESuSCiTATioNeffusion develops acutely, tamponade can occur with as little as 150 mL of fluid. In contrast, chronic effusions can grow to a large volume without haemodynamic instability. Ultrasonographic signs of tamponade include the presence of a pericardial effusion with:• associated right atrial (RA) collapse during ventricular systole• RV diastolic collapse• lack of respiratory variation in inferior vena cava (IVC) and hepatic veinsCompression of the right side of the heart read more..

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    ANSWERS12532. HoldgateA.Sepsisandsepticshock.In:CameronP,JelinekG,KellyA,etal,editors.Textbookofadultemergencymedicine.3rded.Edinburgh:Elsevier;2009.p.57–60.33. SchroederRA,BarbeitoA,Bar-YosefS,etal.Cardiovascularmonitoring.In:MillerRD,ErikssonLI,FleisherLE,etal,editors.Miller’sanesthesia.7thed.Elsevier;2009.p.1267–328.34. read more..

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    126CHAPTER1RESuSCiTATioNresuscitation. In infants and children for whom BVM is unsuccessful, use of the LMA may be considered for either airway rescue or support of ventilation.LMAs should not be used in semiconscious patients or when the gag reflex is present. They are subject to dislodgment during transport. Their use should not replace mastery of BVM ventilation. Children older than 9 years of age may be managed according to adult resuscitation guidelines, although clinical judgement should read more..

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    ANSWERS1275. Answer: DIntraosseous (IO) access in the setting of paediatric and adult resuscitative care is an old intervention that has found its way back into modern critical care. It provides faster and more reliable access than traditional peripheral routes when practitioners are trained in their use. The newer drill devices have not been prospectively shown to actually improve outcomes in paediatric resuscitation, but this question is posed as an area for future research in the ILCOR read more..

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    128CHAPTER1RESuSCiTATioN8. Answer: DChildren generally suffer cardiopulmonary arrest after a respiratory insult, therefore in an unwitnessed arrest attention is given to airway and breathing management – hence CPR first, then call for help. A single rescuer encountering an unwitnessed collapse of an infant or child should start CPR immediately and then obtain assistance. A rescuer witnessing a sudden collapse should obtain help immediately and then start CPR.A variable dose manual read more..

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    ANSWERS129according to a sepsis protocol, which may include early use of inotropes, is a case-by-case decision. Early intubation and mechanical ventilation will decrease the work of breathing and lessen metabolic demand, as well as decrease afterload. However, intubation of a critically unwell child always has the potential for precipitating critical hypotension with cardiac arrest.Parasympathetic cardiac blockade with atropine may be indicated if bradycardia is caused by vagal stimulation or read more..

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    130CHAPTER1RESuSCiTATioNconsistently obtain accurate measurements, pulse oximetry should be used in conjunction with and should not replace clinical assessment of heart rate during newborn resuscitation. Furthermore, saturation monitoring is inconsistent in the first 90 seconds after birth – precisely the period during which heart rate assessment is needed to determine the need for resuscitation.actionGoTo:149,1616. Answer: DWhen babies have meconium-stained amniotic fluid, they are at risk of read more..

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    ANSWERS131the ETCO2 is usually elevated. Level 4 evidence from adult and paediatric case series suggest that ETCO2 readings rise with interventions that increase cardiac output, and may be useful in assessing the quality of interventions such as good chest compression. As an estimate, if the ETCO2 is consistently <15 mmHg, it may indicate the quality of chest compressions is poor or excessive ventilation is decreasing the CO2 level. The ETCO2 must be interpreted with caution for 1–2 minutes read more..

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    132CHAPTER1RESuSCiTATioN13. TibballsJ,CarterB,KiralyNJ,etal.BiphasicDCshockcardiovertingdosesforpaediatricatrialdysrhythmias.Resuscitation2010;81:1101–4.14. FiserRT,WalkerWM,SeibertJJ,etal.Tibiallengthfollowingintraosseousinfusion:aprospective,radiographicanalysis.PediatrEmergCare1997;13:186–8.15. LaRoccoBG,WangHE.Intraosseousinfusion.PrehospEmergCare2003;7:280–5.16. read more..

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    ANSWERS1331. Answer: AA detailed history obtained from the patient regarding the nature of chest pain is important for the diagnosis and risk stratification. The positive likelihood ratios (LRs) have been determined for various descriptions of chest pain. The positive LR for pain radiating to the right arm or shoulder as an indicator of myocardial infarction is 4.7 compared with LR of 2.3 for pain radiating to left arm. The positive LR for pain radiating to both arms and shoulders is 4.1. read more..

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    134CHAPTER2CARdiovASCulAREmERgENCiESTABlE2.1SENSiTiviTYANdSPECiFiCiTYiNTHEdiAgNoSiSoFAmiuSiNgHIGH-SENSITIVITYTRoPoNiNASSAYS(WHENACuT-oFFvAluEoF0.07mCg/loR99THPERCENTilEiSuSEd)Duration since presentation with chest pain30 min 2 hours 3 hoursCumulative sensitivity93%98%100%SpecificityN/A57%54%TABlE2.2TimiSCoREiNTERPRETATioNTIMI score% of risk0–14.728.3313.2419.9526.26–740.94. Answer: BST elevation in leads II, III and aVF suggests an inferior infarction that may involve the right coronary or read more..

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    ANSWERS135• ST segment elevation ≥1 mm concordant with the QRS complex• ST segment depression ≥1 mm in V1, V2 or V3• ST elevation ≥5 mm discordant with the QRS complex.Only 1–2% of patients presenting with ischaemic symptoms to the ED have a new or presumed new (not known to be old) LBBB. The first Sgarbossa criterion, ST segment elevation ≥1 mm that is concordant with the QRS complex, if present, seems to be the most specific in diagnosing AMI in those patients. However, the read more..

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    136CHAPTER2CARdiovASCulAREmERgENCiESPCI is the reperfusion treatment of choice for cardiogenic shock associated with AMI.Tenecteplase has a higher risk of intracranial haemorrhage than streptokinase. Thrombolysis has a higher risk of bleeding-related adverse effects in females (because they generally weigh less), the elderly and patients with hypertension.The number needed to treat (NNT) to save a life for inferior STEMI is approximately actionGoTo:161,100–120.11,1511. Answer: DAspirin alone read more..

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    ANSWERS137failure are at higher risk of cardiogenic shock. Early revascularisation with PCI or coronary artery bypass graft (CABG) has a mortality benefit, with vasopressors, inotropes and intra-aortic balloon pump being useful as a bridge to reperfusion. PCI or CABG is preferable to thrombolysis. Thrombolysis is only really indicated if timely transfer to a facility with PCI or CABG is not actionGoTo:161,available.2215. Answer: BInotropes alone do not alter outcome but may temporise until read more..

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    138CHAPTER2CARdiovASCulAREmERgENCiESECG findings may be present for several months following acute pericarditis. Generally the ECG will follow four stages:1. (hours to days) concave upwards ST elevation and PR depression2. normalisation of the PR and ST segments3. (days to weeks) T wave inversion4. (up to 3 months) normalisation of ECG.Q waves suggest full wall thickness myocardial actionGoTo:162,infarction.2821. Answer: CPatients with cardiac tamponade usually display tachycardia, low systolic read more..

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    ANSWERS13923. Answer: CMultiple sets of blood cultures prior to antibiotic treatment will yield a microbiological diagnosis in at least 95% of cases. In the toxic patient, empirical antibiotic treatment should be given after three sets of blood cultures from different sites. Otherwise antibiotics should be delayed until blood cultures are positive.With respect to right-sided endocarditis in intravenous drug users, the most common valve involved is the tricuspid valve (tricuspid 45%, mitral 30% read more..

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    140CHAPTER2CARdiovASCulAREmERgENCiES• fusion beats• capture beats• concordance of the QRS axis across the precordial leads.RBBB morphology is more likely to be SVT with aberrancy, although an rSR morphology suggests VT. VT may be slower than 140 beats per minute in patients taking cardioactive medications (e.g. amiodarone).actionGoTo:162,38,4029. Answer: ACannon A waves result from dissociation between atrial and ventricular activity and in this setting indicate that VT is the likely read more..

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    ANSWERS14136. Answer: DTachycardia associated with Wolff-Parkinson-White syndrome (WPW) can be:• reentrant tachycardia with orthodromic/antegrade conduction down the AV node, resulting in a concealed pathway and narrow complex tachycardia – the most common reentrant tachycardia of WPW• reentrant tachycardia with antidromic conduction down the accessory pathway, resulting in a wide complex QRS• rapid conduction of atrial tachycardia through the accessory pathway.Verapamil, digoxin, read more..

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    142CHAPTER2CARdiovASCulAREmERgENCiES(>0.12 second) AF, the heart rate can be higher than 250/min. This rapid ventricular response can degenerate into ventricular fibrillation (VF) and lead to potential death.In AF not related to preexcitation syndromes, the relatively long refractory period in the AV node protects the ventricle from achieving very high rates, therefore preventing AF degenerating into VF.Calcium channel blockers, beta-blockers and digoxin prolong the refractory period in AV read more..

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    ANSWERS143electrical and muscle activity than modern bipolar electrodes.actionGoTo:162,3946. Answer: BTetralogy of Fallot results in right heart outflow obstruction, causing right to left shunting and cyanosis. Treatment aims to decrease right to left shunting.The ideal position for these children is the ‘squatting’ position where afterload is increased, therefore decreasing shunt size. For the same reason, vasoconstrictors such as metaraminol can be used. Crying will increase pulmonary read more..

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    144CHAPTER2CARdiovASCulAREmERgENCiES50. Answer: AChildhood hypertension is defined as either systolic or diastolic BP ≥95th percentile of the normal values for the age and the height and BP between 90–95th percentile is defined as prehypertension. Although hypertension is an infrequent finding in children presenting to an ED it requires thorough assessment to identify and treat a secondary cause. The aetiology depends on the age. Renal parenchymal disease such as glomerulonephritis is rare read more..

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    ANSWERS14524. LeeM.Hypertension.In:CameronP,JelinekG,KellyA,etal,editors.Textbookofadultemergencymedicine.3rded.Edinburgh:ChurchillLivingstonElsevier;2009.p.259–62.25. GrayR.Hypertension.In:MarxJ,HockbergerR,WallsR,etal,editors.Rosen’semergencymedicine:conceptsandclinicalpractice.7thed.MosbyElsevier;2009.p.1076–87.26. ComanM.Aorticdissection.In:CameronP,JelinekG,KellyA,etal,editors.Textbookofadultemergencymedicine.3rded.Edinburgh:ChurchillLivingstonElsevier;2009.p.263–8.27. read more..

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    146CHAPTER3REsPiRAToRyEmERgEnCiEs1. Answer: DDifferentiating the cause for dyspnoea in a patient presenting to the ED can be challenging because both congestive cardiac failure and pulmonary conditions such as COPD may coexist, especially in the elderly population. Contrary to popular belief, symptoms such as dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea and leg oedema have a low positive likelihood ratio (LR) for the diagnosis of congestive cardiac failure (CCF). Previous read more..

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    AnsWERs147• cirrhosis• nephrotic syndrome• superior vena cava obstruction• myxoedema.Exudative causes include:• parapneumonic effusions – bacterial pneumonia, bronchiectasis, lung abscess• malignancy – 75% are due to lung carcinoma, breast carcinoma and lymphoma• other infective causes – tuberculosis, viral, fungal and parasitic infections• PE• collagen vascular disease.A diagnostic thoracocentesis should be performed and pleural fluid should be tested for protein and LDH read more..

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    148CHAPTER3REsPiRAToRyEmERgEnCiEsimmunisation schedules this subset of patients is not protected, as three or more injections are required to confer protection. The current Australian immunisation schedule recommends vaccination against pertussis at 2, 4 and 6 months of age, with a booster at 4 years. Furthermore, maternal antibodies do not guarantee protection of the neonate against developing pertussis and it is recommended that women in the last trimester of pregnancy who have been exposed read more..

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    AnsWERs149TABLE3.2CoRBsCoREParameterPointsCConfusion (new)1OOxygen saturation 90% or less1RRespiratory rate 30/min or more1BBP – systolic < 90 mm Hg or diastolic < 60 mm Hg1Patients with 2 or more points is considered as having severe CAP and a high risk of needing actionGoTo:177,IRVS.12,138. Answer: DThe evidence suggests that routine use of blood cultures to diagnose the aetiological agent in a patient who is likely to have CAP is of low value. In admitted patients only up to 16% of read more..

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    150CHAPTER3REsPiRAToRyEmERgEnCiEshence associated with higher incidence of septic shock and mortality.actionGoTo:177,12,1411. Answer: DVirulent strains of community-associated methicillin-resistant S. aureus (CA-MRSA) are increasingly becoming more prevalent in many parts of Australia including Queensland, NSW and the ACT. These strains can cause severe skin infections such as furunculosis, as well as rapidly fatal severe CAP. This severe pneumonia usually occurs in previously healthy children read more..

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    AnsWERs151a result of reduced host defence mechanisms (due to destruction of air passages), a perpetual cycle of recurrent infections and further inflammation, obstruction and destruction occurs. Secretions accumulate and bacteria colonise obstructed air passages. The organisms found most typically include Haemophilus species and Pseudomonas species. These organisms can cause ongoing damage and episodic infectious exacerbations.The reason for ED presentations is often acute exacerbations due to read more..

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    152CHAPTER3REsPiRAToRyEmERgEnCiEs18. Answer: CIn a supine patient, including trauma patient, bedside ultrasound can be used to detect or exclude an anteriorly placed pneumothorax. Some of these pneumothoraces are not visualised on a supine chest radiograph. In a trauma patient, the low-frequency curvilinear probe can be used in an extended FAST (eFAST) to look for a pneumothorax. In others, either high-frequency linear probe or curvilinear probe can be used. In the absence of pleural adhesions read more..

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    AnsWERs153going to be mechanically ventilated. The following catheter sizes are generally acceptable.• For a small pneumothorax, a small size catheter/tube (10F–14F).• For a large pneumothorax, a medium size tube (16F–22F).Between 2 and 7% of spontaneous pneumothoraces have associated blood in the thoracic cavity (haemopneumothorax). If this is expected or visible on imaging, a large tube (24F–36F) should be used. French tube size represents the diameter of the tube. 1 French means a read more..

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    154CHAPTER3REsPiRAToRyEmERgEnCiEs24. Answer: AA single dose of intravenous magnesium sulphate is an effective adjunct in the treatment of severe asthma. The usual recommended dose in adults is 1.2–2 g and 50 mg/kg in children, given slowly via IV over 20–30 minutes. There is evidence to suggest that the response from the drug is greatest in patients with most severe airflow obstruction due to bronchospasm on presentation to the ED. Therefore, it is not recommended for routine use in mild to read more..

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    AnsWERs155and is affected by the degree of hyperinflation. Ideally this should be maintained at <25 cm H2O.There is a paucity of randomised trial data regarding the use of NIV in asthma. Some case series suggest benefit. There are as yet no clear guidelines for the use of NIV in severe asthma. A trial of NIV is reasonable once patients are screened for contraindications and are willing to cooperate.Similarly, there is a paucity of good evidence regarding the use of IV salbutamol. However, IV read more..

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    156CHAPTER3REsPiRAToRyEmERgEnCiEs30. Answer: BSpirometry is indicated in all patients presenting with acute exacerbations of COPD except rare occasions of altered level of consciousness. FEV 1.0 manoeuvre can be performed by even unwell COPD patients with a normal conscious state. When FEV 1.0 is <1 L or <40% predicated, it usually indicates a severe exacerbation in a patient with mild to moderate disease.In a patient with advanced disease (severe COPD), worsening hypoxaemia, acute read more..

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    AnsWERs15733. Answer: AThe use of NIV in patients presenting with an acute exacerbation of COPD, in addition to usual medical care, is associated with reductions in mortality, need for intubation and treatment failure. NIV should be considered early in the course of respiratory failure before severe acidosis ensues (in line with global and Australasian guidelines). This may reflect the benefit of starting earlier in the process when respiratory muscles are less fatigued.Indications for NIV read more..

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    158CHAPTER3REsPiRAToRyEmERgEnCiEs36. Answer: BVenous thromboembolism (DVT and/or PE) occurs in 0.1% of pregnancies. At least in 50% of these cases it is associated with an inherited or acquired thrombophilia (a disorder of haemostasis that predisposes an individual to thrombotic events). However, thrombophilia screening done in pregnant patients with DVT or PE will add minimal value in the treatment of these patients during the current pregnancy. The results obtained during the pregnancy can read more..

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    AnsWERs159The authors of PERC estimated that this testing threshold for further testing to be 1.8% and the PERC is based on this assumption. In other words, a missed rate of 1.8% is acceptable to defer diagnostic testing that may cause more harm than the disease itself. In a recent study this testing threshold was found to be 1.4%. However, PERC can be applied only to patients with a suspected PE with a low pretest probability according to the clinician’s overall clinical impression or read more..

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    160CHAPTER3REsPiRAToRyEmERgEnCiEsReferences1. SarkoJ,StapczynskiJ.Respiratorydistress.In:TintinalliJ,StapczynskiJ,MaO,etal,editors.Tintinalli’semergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGrawHillMedical;2011.p.465–73.2. CollingsJ.Acid–basedisorders.In:MarxJ,HockbergerR,WallsR,etal,editors.Rosen’semergencymedicine:conceptsandclinicalpractice.7thed.Philadelphia:MosbyElsevier;2010.p.1640–14.3. read more..

  • Page - 178

    REFEREnCEs16131. JoostenS,KohM,BuX,etal.Theeffectsofoxygentherapyinpatientspresentingtoanemergencydepartmentwithexacerbationofchronicobstructivepulmonarydisease.MJA2007;186:235–8.32. AbramsonM,BrownJ,CrockettA,etal.COPD-Xplan:AustralianandNewZealandguidelinesformanagementofchronicobstructivepulmonarydisease.Online.Available:actionURI(http://www.copdx.org.au):www.copdx.org.au;25May2011.33. read more..

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    162CHAPTER4NEuRologiCAlANdNEuRosuRgiCAlEmERgENCiEs1. Answer: DMigraine headache can be associated with two types of symptoms:• prodromal symptoms• symptoms of aura.The usual prodromal symptoms are lethargy, yawning, hyperactivity and food craving. These symptoms start many hours before the onset of headache.The majority of migraine headaches are not associated with an aura. When associated with aura, it can precede or accompany the headache. Aura does not usually last more than 60 minutes. A read more..

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    ANsWERs1634. Answer: BTemporal arteritis is a steroid-responsive large-vessel vasculitis with both local arteritic and non-specific systemic inflammatory features. This condition itself is relatively rare.Local arteritic features include:• temporal artery abnormalities such as• beading• irregularity• tenderness• pulselessness• jaw claudication (34% of patients have this symptom)• visual loss and ischaemic optic neuropathy• scalp and tongue necrosis• diplopia.Systemic features read more..

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    164CHAPTER4NEuRologiCAlANdNEuRosuRgiCAlEmERgENCiEs7. Answer: CCerebral vasospasm is most common in 2 days to 3 weeks. There is moderate protective benefit with nimodipine, and this should be started within 96 hours. The need for seizure prophylaxis is controversial. One in 5 patients with SAH will have at least one seizure. Delayed cerebral ischaemia is known to be associated with hyperglycaemia, hypothermia and hyperthermia. Rebleeding can be reduced by adequate BP control. Ideal target BP is read more..

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    ANsWERs165with sparing of the hand and face), contralateral hemisensory loss, homonymous hemianopia and gaze preference towards the side of the infarct. If the dominant hemisphere is affected (left in right-handed people and 80% of left-handed), aphasia or dysphasia (receptive, expressive or both) can be expected. Inattention, neglect, constructional apraxia and dysarthria (without aphasia) may occur if the non-dominant hemisphere is affected. In the absence of other exclusion criteria, to be read more..

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    166CHAPTER4NEuRologiCAlANdNEuRosuRgiCAlEmERgENCiEsoutcomes in ischaemic stroke. However, there is no consensus about an ideal BP during the treatment of ischaemic stroke. According to the National Institute of Neurological Disorders and Stroke (NINDS) eligibility criteria for thrombolysis in stroke, a BP over 185/110 is a contraindication for thrombolysis and a reduction in BP below this level should be carefully attempted, using titratable intravenous agents. BP should also be maintained during read more..

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    ANsWERs167cervical arterial dissection peaks in the fifth decade of life. A variety of risk factors have been identified and those include major neck trauma, trivial neck manipulations, migraine and connective tissue disorders. Atherosclerosis and hypertension are not considered risk factors. Typical early symptoms are unilateral headache, neck pain and facial pain for internal carotid artery dissection and both unilateral or bilateral occipital headache and posterior neck pain for vertebral read more..

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    168CHAPTER4NEuRologiCAlANdNEuRosuRgiCAlEmERgENCiEsas Ménière’s disease, vestibular neuronitis, or viral or bacterial labyrinthitis, in BPPV these symptoms are not present. In BPPV examination of the middle ear is usually normal; alternatively, in labyrinthitis changes in the middle ear due to otitis media is a significant finding.actionGoTo:187,2122. Answer: AGeneralised convulsive status epilepticus has been traditionally defined as a seizure lasting more than 30 minutes or two or more read more..

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    ANsWERs169other stimuli, no motor activity (except blinking of the eyes), no urinary incontinence and no tongue biting during the episodes. The seizure activity terminates abruptly and there is no postictal phase. Absence seizures can occur many times a day and can go unrecognised. These seizures can occur in patients presenting to the ED with other types of seizures or they can occur alone.Intact consciousness and mentation is a hallmark of simple partial seizures where seizure activity remains read more..

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    170CHAPTER4NEuRologiCAlANdNEuRosuRgiCAlEmERgENCiEsmay coexist with features for shunt obstruction. Fever and meningism may not be present and lumbar puncture findings are unreliable for diagnosis. Neurosurgical referral for shunt tap for microbiological testing is indicated.actionGoTo:188,3130. Answer: BInfant botulism is a rare presentation but has been reported in Australasian hospitals. Because of the rarity of the condition and the less overt nature of clinical features, the diagnosis is read more..

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    REFERENCEs17124. LowensteinDH,CloydJ.Out-of-hospitaltreatmentofstatusepilepticusandprolongedseizures.Epilepsia2007;48(Suppl.8):96–8.25. ShearerP,RivielloJ.Generalisedconvulsivestatusepilepticusinadulsandchildren:treatmentguidelinesandprotocols.EmergMedClinNAm2011;29:51–64.26. ChangA,ShinnarS.Nonconvulsivestatusepilepticus.EmergMedClinNAm2011;29:65–72.27. McMickenD,LissJ.Alcohol-relatedseizures.EmergMedClinNAm2011;29:117–24.28. read more..

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    172CHAPTER5EndoCRinEEmERgEnCiEs1. Answer: DUlcer development in the feet of people with diabetes is promoted by peripheral neuropathy, impaired circulation in macrovascular and microvascular beds, plantar pressure, recurrent trauma and delayed wound healing. Unlike those due to venous or vascular insufficiency, diabetes-related ulcers occur particularly in pressure-bearing areas such as the sole of the foot.Diabetic peripheral neuropathy consists of a number of heterogenous nerve dysfunction read more..

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    AnsWERs173normalisation when a patient has an altered mental status due to hypoglycaemia. Due to its mechanism of action, it is less effective in patients with low glycogen stores such as chronic alcoholics or children.The critical level for a patient to develop symptomatic hypoglycaemia varies between individuals, but symptoms start usually below 5 mmol/L. The adrenergic response to hypoglycaemia may be prevented by the use of β-receptor antagonists, but not by calcium channel read more..

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    174CHAPTER5EndoCRinEEmERgEnCiEsbicarbonate is not recommended to correct acidosis except in a limited subset of patients including patients who are critically unwell with arterial pH < 6.9 (severe actionGoTo:197,acidaemia).1,38. Answer: CCerebral oedema is a serious complication that occurs (especially in children) during treatment of DKA. It has a mortality risk of 70% once developed, with 10% of survivors having permanent neurological sequelae. Cerebral oedema usually develops when it read more..

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    AnsWERs175depletion. Hypernatraemia along with very high serum osmolality, are poor prognostic factors and correspond to severe volume depletion. Fluid replacement, guided by central venous pressure (CVP) monitoring if necessary, should aim first to correct hypotension, then to slowly replace water deficit over a period of several actionGoTo:197,days.1,511. Answer: DThe diagnosis of underlying osteomyelitis associated with a diabetic foot ulcer can be difficult. A diabetic foot ulcer extending read more..

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    176CHAPTER5EndoCRinEEmERgEnCiEsdisorders including primary adrenal insufficiency (Addison’s disease).Hyperpigmentation occurs in the presence of primary adrenal failure when adrenocorticotropic hormone (ACTH) levels are elevated in the absence of negative feedback. Elevated ACTH levels stimulate melanin production in skin and mucosa. The most common cause of secondary adrenal insufficiency is chronic glucocorticoid therapy inhibiting ACTH production, and so suppressing primary adrenal read more..

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    AnsWERs177proptosis may both continue to deteriorate despite correcting the hormone imbalance. Tarsorrhaphy may be indicated in thyroid ophthalmopathy to protect the cornea from drying and ulceration.actionGoTo:197,720. Answer: BPatients may present acutely with thyrotoxic periodic paralysis. Hypokalaemia is generally present during these attacks, which may be recurrent. The condition is distinct from familial periodic paralysis, a group of inherited disorders.Graves’ disease is due to a type read more..

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    178CHAPTER5EndoCRinEEmERgEnCiEsrate. Patients are often elderly and frail, and may have associated comorbidities. For these reasons, the patient must be intensively monitored.Supportive care includes:• attention to airway, breathing and circulation• treatment of hypoglycaemia and hyponatraemia• vasopressor support for hypotension• treatment of associated adrenal insufficiency with intravenous hydrocortisone• treatment of the underlying infection with intravenous antibiotics.These read more..

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    AnsWERs179elevated blood pressure, which is invariable at presentation. Patients may present with muscle weakness due to hypokalaemia, or polyuria due to nephrogenic diabetes insipidus related to renal tubular damage.actionGoTo:197,728. Answer: AIn 80–90% of cases causes of hypercalcaemia in patients presenting to the ED include:• primary hyperparathyroidism• parathyroid adenoma (most common)• parathyroid hyperplasia• parathyroid carcinoma• as a part of multiple endocrine neoplasia read more..

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    180CHAPTER5EndoCRinEEmERgEnCiEs• cardiovascular complications of hypertension (hypertensive crisis, myocardial infarction, aortic dissection, cardiac arrhythmias, heart failure, cardiomyopathy, pulmonary oedema, CVA).30. Answer: DPatients with type 1 and type 2 diabetes who are on insulin treatment commonly present to the ED with uncomplicated hyperglycaemia for stabilisation. These patients routinely are on one of the following insulin regimes:• basal insulin only (once-daily long-acting read more..

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    REFEREnCEs18111. IdroseA.Thyroiddisorders:hypothyroidismandmyxedemacrisis.In:TintinalliJ,StapczynskiJ,MaO,etal,editors.Tintinalli’semergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGrawHillMedical;2011.p.1444–7.12. MillsL.Emergentmanagementofacutesymptomsofhypopituitarism.MedscapeReference:drugs,diseasesandprocedures.Jun17,2011.WebMDLLC.Online.Available:actionURI(http://emedicine.medscape.com):http://emedicine.medscape.com.13. read more..

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    182CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEs1. Answer: CA recent systematic review showed that prolonged capillary refill time, abnormal skin turgor and abnormal respiratory pattern were the three best clinical signs for identifying dehydration, whereas laboratory tests were often unhelpful and non-specific.Historically, in the 1990s, the severity of dehydration was classified as 1) mild (3–5%), 2) moderate (6–9%) and 3) severe (>10%). However, increasing evidence shows that signs of read more..

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    AnsWERs183potassium and have a high sugar content and high osmolarity, may exacerbate diarrhoea and dehydration and cause electrolyte disturbance. Therefore, their use is not recommended in children with evidence of dehydration.actionGoTo:212,3–123. Answer: DTraditionally, a period of fasting has been recommended. However, current recommendations suggest early introduction of an age-appropriate diet with the early reintroduction of cow’s milk, milk formula or solid food as soon as the child read more..

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    184CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEsAlternatively, the patient can be admitted for observation. All children with severe disease (≥ 6 stools per day), who are systemically unwell (fever, tachycardia) or with abdominal complications, should be admitted. Children with persistent (>7 days) of bloody diarrhoea should be referred for further investigation of other causes, including actionGoTo:213,IBD.13–155. Answer: AThe causes of travellers’ diarrhoea depend on the destination, setting read more..

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    AnsWERs185intolerance of metronidazole, or failure to respond to metronidazole after 3–5 days of treatment.Ideally, all antibiotic treatment should be oral since C. difficile is restricted to the lumen of the colon. If intravenous treatment is required, only metronidazole (and not vancomycin) is effective, since this approach will still result in moderate concentrations of the drug in the colon. Intravenous vancomycin generally is not effective because it does not reach effective intraluminal read more..

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    186CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEsused to establish disease severity in patients with ulcerative colitis (see actionGoTo:203,Table 6.1).The Crohn’s Disease Activity Index is a useful score in determining the disease severity of CD and uses the following parameters in the assessment:• stool frequency• abdominal pain• general wellbeing and opiate use• presence of complications• abdominal masses• anaemia• weight lossPlain abdominal and chest radiographs are essential to read more..

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    AnsWERs187absence of H. pylori may have prognostic implications. H. pylori-negative ulcers appear to have a significantly worse outcome, especially if treated empirically for infection.Various non-invasive techniques are available. The urea breath test is one such test that is highly sensitive and specific and is also useful in assessing eradication. H. pylori tests cannot demonstrate the presence of PUD but a negative test in patients not taking NSAIDs makes the likelihood of PUD low. Testing read more..

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    188CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEsassociated with poorer outcomes in upper GIT bleeds but haematochezia is associated with a three times higher risk of death.Haematochezia is the passage of bright red or maroon-coloured blood per rectum and suggests a source distal to the ligament of Treitz. Approximately 14% of bleeds presenting with hematochezia are caused by a brisk upper source with rapid transit. Haematochezia due to an upper tract source of bleeding has been associated with a higher read more..

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    AnsWERs189Peptic ulcer disease may be painless, especially in the elderly and particularly in those taking NSAIDs or steroids. Rectal examination and faecal occult blood testing should be performed in all patients with suspected upper GIT bleeding. A positive test requires at least 8 mg of haemoglobin per gram of stool. A positive guaiac test is dependant on the time of onset of the bleeding in relation to gastrointestinal transit time. It is therefore possible that in some acute bleeds, the read more..

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    190CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEsprophylaxis in cirrhotic patients with gastrointestinal bleeding improves mortality and reduces the risk of further bleeding. Gram-negative bacteria have been most commonly isolated in these patients. Fluoroquinolones have been traditionally used in the past but recent resistance patterns have encouraged the use of third-generation cephalosporins.actionGoTo:213,30,3119. Answer: DA normal liver span usually measures 8–13 cm in the midclavicular line. read more..

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    AnsWERs191every 3–5 days (maintaining the 100 mg: 40 mg ratio) if weight loss and natriuresis are inadequate. Usual maximum doses are 400 mg/day of spironolactone and 160 mg/day of furosemide. Spironolactone can be used as a single agent; however, hyperkalaemia and its long half-life limit its use. As a result, it is mainly reserved for patients with minimal fluid overload. Single-agent furosemide has been shown to be less efficacious than spironolactone. Starting with both drugs appears to be read more..

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    192CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEsabdomen during a therapeutic tap for intervals of an hour or more without injury. An 18-gauge needle is preferred for large-volume therapeutic paracenteses because this permits expeditious outflow, whereas a smaller-gauge (20- to 22-gauge) needle may be sufficient for diagnostic taps and lessen the likelihood of post-procedural ascitic fluid leak through the wound site. Plastic sheath cannulas tend to kink and run the risk of being sheared off into the read more..

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    AnsWERs193Polymicrobial and anaerobic infections have been reported but are not common. A third-generation cephalosporin, such as cefotaxime, is usually sufficient in treating SBP. Anaerobic coverage should be added if secondary peritonitis is actionGoTo:213,suspected.39,41–4325. Answer: CLactulose, a nonabsorbable disaccharide, is the first-line treatment in patients with hepatic encehalopathy. It is effective via various mechanisms:• It reduces the intestinal production and absorption of read more..

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    194CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEscells, for example, the heart, smooth muscle, kidney and brain. Therefore, ALT is a more specific marker of hepatocyte injury than AST.• Alcohol stimulates AST production. Subsequently, an AST : ALT ratio >2 is common in alcoholic hepatitis.• With viral hepatitis, AST and ALT levels increase over 1–2 weeks to levels in the thousands, and return to normal within 6 weeks in uncomplicated cases.• In cholestatic disorders, AST increases before ALT, read more..

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    REFEREnCEs1951. <1 monthFever is usually due to complications of surgery and hospitalisation. Nosocomial pathogens are prominent.2. 1–6 monthsa) immunomodulating viral infections including cytomegalovirus (CMV), hepatitis B and C, and Epstein-Barr virus (EBV)b) opportunistic infections including Pneumocystis, Listeria, and fungal species3. >6 monthsInfections are further divided into three groups relative to infection susceptibility:a) healthy transplant – community-acquired read more..

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    196CHAPTER6GAsTRoEnTERoloGiCAlEmERGEnCiEs12. CentreforDiseaseControlandPrevention.Managingacutegastroenteritisamongchildren:Oralrehydration,maintenance,andnutritionaltherapy.CentreforDiseaseControlandPrevention.Online.Available:actionURI(http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm):http://www.actionURI(http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm):cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm;2011.13. read more..

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    REFEREnCEs19745. SundaramV,ShaikhOS.Hepaticencephalopathy:pathophysiologyandemergingtherapies.MedClinNAm2009;93:819–36.46. read more..

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    198CHAPTER7REnAlEmERgEnCiEs1. Answer: CARF itself is usually asymptomatic until severe uraemia has developed. More commonly, patients will present with symptoms of the underlying cause.Papillary necrosis results from ischaemia of the renal medullary pyramids and papillae. This is usually associated with diabetes mellitus, analgesic use, pyelonephritis and urinary obstruction. Presenting symptoms in the acute form include fever and chills, flank or abdominal pain and haematuria. It may also read more..

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    AnsWERs199angiotensin II act to diminish renal blood flow and GFR. NSAIDs do not usually impair renal function in healthy persons.Angiotensin-receptor blockers can also precipitate renal failure, most likely due to a similar mechanism as mentioned above.actionGoTo:222,1,3,45. Answer: AThere is a misconception that traditional serum markers of myocardial damage (CK and troponin) are unreliable in dialysis patients presenting with chest pain. These markers are, however, not significantly elevated read more..

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    200CHAPTER7REnAlEmERgEnCiEsaccount for more inpatient hospital days than any other complication of haemodialysis. Vascular access complications include failure to provide adequate flow for dialysis, infection, bleeding, vascular access aneurysm and pseudoaneurysms, vascular insufficiency of the extremity distal to the vascular access and high-output heart failure. Failure to provide adequate flow for dialysis and infection are by far the two most common complications.The inability to obtain read more..

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    AnsWERs20111. Answer: DIntravenous insulin is the most reliable agent for shifting potassium into cells and is regarded as the first-line treatment for hyperkalaemia. Its onset of action is rapid within 15–30 minutes.β-receptor agonists have a similar onset of action and their effect has been shown to be additive to insulin administration. However, the effective dose is at least 4 times higher than typically used for bronchodilation. Salbutamol at doses of 10–20 mg is recommended via a read more..

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    202CHAPTER7REnAlEmERgEnCiEsAdditionally, it seems like an initially elevated serum urea and creatinine and a large base deficit have an increased risk for developing ARF.actionGoTo:222,16–1814. Answer: DHUS is primarily a disease of infancy and early childhood, especially of those aged between 6 months and 4 years and is rare after 5 years of age. It is classically characterised by the triad of microangiopathic haemolytic anaemia, thrombocytopaenia and ARF.Two forms of HUS exist: epidemic read more..

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    AnsWERs203Serum complements, antibodies and coagulation factors are lost as protein in the urine, making these children susceptible to severe infection and thromboembolic events. Steroid therapy further increases the infection risk. Hyperlipidaemia may lead to hyperviscosity and further increase the thrombotic risk.actionGoTo:223,19,2018. Answer: DThe causes of haematuria can be divided into haematologic, renal and postrenal causes. Renal causes may be further classified as glomerular or read more..

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    204CHAPTER7REnAlEmERgEnCiEsusually yield a negative nitrate test. Although nitrate reaction by dipstix has a very high specificity (90%) and a positive result is useful in confirming diagnosis of UTI, it has a low sensitivity (about 50%) so it is not always useful as a screening exam because a negative test does not exclude the diagnosis of UTI.Visual inspection and assessment of the odour of urine is generally not helpful in determining infection. Cloudiness in fresh urine is usually not due to read more..

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    REFEREnCEs205associated with recurrence include young age at first UTI, urinary tract abnormalities including VUR, and voiding dysfunction.actionGoTo:223,31,3225. Answer: AGuidelines referring to the appropriate investigations that should be performed in children with a first UTI remain controversial.It is generally recommended that renal ultrasound should be performed in all young children after an initial febrile UTI, mainly to detect anatomical abnormalities, ureteral and calices dilation and read more..

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    206CHAPTER7REnAlEmERgEnCiEsmedicine:acomprehensivestudyguide.7thed.NewYork:McGrawHillMedical;2011.p.622–4.18. BoschX,PochE,GrauJM.Reviewarticle:Rhabdomyolysisandacutekidneyinjury.NEnglJMed2009;361:62–72.19. KoernerC.Renalemergenciesininfantsandchildren.In:TintinalliJ,StapczynskiJ,MaO,etal,editors.Tintinalli’semergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGrawHillMedical;2011.p.866–72.20. read more..

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    ANSWERS2071. Answer: BFully cross-matched blood refers to blood that is: ABO and Rh typed; screened for antibodies; and compatibility tested with the donor’s blood to identify the potential for a transfusion reaction. This involves mixing the donor’s RBCs and serum with the recipient’s red blood cells (RBCs) and serum. Testing is performed immediately after mixing, after incubation at 37°C for varying times, and with and without an antiglobulin reagent to identify surface immunoglobulin read more..

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    208CHAPTER8HAEmATologiCAlANdoNCologiCAlEmERgENCiESof rFVIIa is for patients with critical bleeding unresponsive to conventional measures of surgical haemostasis and adequate component therapy. This use remains controversial, particularly because of concerns about the risk of potential thrombotic complications. Currently, the routine use of rFVIIa in trauma patients with critical bleeding requiring massive transfusion is not recommended because of its lack of effect on mortality and variable read more..

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    ANSWERS209blood count (FBC), coags, urea and electrolytes test (U&E), haptoglobin, indirect bilirubin, lactate dehydrogenase (LDH), plasma free Hb, urine for Hb and the blood returned to the bank for testing. While lab confirmation is being performed, the sequel of haemolysis is treated supportively. Transfusion reactions are due to a specific interaction between a particular unit and a particular patient, therefore if a blood transfusion is still indicated, blood can be collected for retype read more..

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    210CHAPTER8HAEmATologiCAlANdoNCologiCAlEmERgENCiESOral vitamin K1 is the route of choice as the intravenous route, although it produces a more rapid reversal, may be associated with anaphylactic reactions. There is no evidence that this rare, but serious, complication can be avoided by using low doses. In Australia and New Zealand, vitamin K1 is a mixed micelle-based formulation, and may not carry the same risk of allergies, including anaphylaxis, as earlier formulations. The formulation of read more..

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    ANSWERS2118. Answer: AThe mean corpuscular volume (MCV) is the most useful guide to the possible aetiology of anaemia and is used to classify the anaemic process as microcytic, normocytic and macrocytic. The RDW measures the size variability of the RBC population and is useful in distinguishing the deficiency anaemias (iron, vitamin B12, or folate) from other causes. It may be increased in early deficiency anaemia (iron, vitamin B12 or folate) even before the MCV becomes abnormal. RDW is also read more..

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    212CHAPTER8HAEmATologiCAlANdoNCologiCAlEmERgENCiESand well-granulated, suggesting a platelet destructive state. The presence of any other abnormality on peripheral smear would suggest an alternate actionGoTo:234,diagnosis.19,2011. Answer: DThis child most likely has idiopathic thrombocytopaenic purpura (ITP); the result of thrombocytopaenia caused by immune destruction of platelets, often precipitated by intercurrent viral infections. Acute ITP is more common in young children and typically read more..

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    ANSWERS21313. Answer: DFever in cancer patients are defined as a single oral temperature ≥ 38.3°C, or an elevation of 38°C on at least 2 occasions or persisting >1 hour. All patients presenting with fever following chemotherapy should be assumed neutropenic until proven otherwise. Although rectal measurement most accurately reflects core body temperature, the theoretical risk of bacterial translocation during the procedure of inserting the thermometer into the anus is not recommended in read more..

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    214CHAPTER8HAEmATologiCAlANdoNCologiCAlEmERgENCiESand urine output. This counteracts precipitation of uric acid and calcium phosphate crystals in distal nephrons. The use of furosemide or mannitol for osmotic diuresis has not proven to be beneficial as first-line therapy. Instead, diuretics should be reserved for well-hydrated patients with insufficient diuresis, and furosemide alone should be considered for normovolaemic patients with hyperkalaemia or for the patients with evidence of fluid read more..

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    ANSWERS215replacement of bone marrow by malignant cells and secondary bone marrow failure. Deep bone pain due to marrow involvement is not associated with tenderness. However, bone and periosteal leukaemic infiltration may have exquisite tenderness over the bone. Bone marrow infiltration with leukaemia ‘blasts’ results in anaemia, thrombocytopaenia and neutropenia, which often manifest as fever and infection, pallor, easy bleeding and petechiae. The peripheral white blood cell count may be read more..

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    216CHAPTER8HAEmATologiCAlANdoNCologiCAlEmERgENCiESchildhood cancer. Medulloblastoma, a neuronal tumour of the posterior fossa, is the most common malignant brain tumour in children. A large study of 3300 newly diagnosed pediatric brain tumour patients performed by the Childhood Brain Tumor Consortium reported that nearly two-thirds of patients had chronic or frequent headaches before their first hospitalisation. However, headache is a common complaint in the pediatric population with the read more..

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    REFERENCES2172009;58(7):346–52.Online.Available:actionURI(http://www.jfponline.com):http://www.actionURI(http://www.jfponline.com):jfponline.com;10Aug2011.12. AnsellJ,HirshJ,HylekE.Antithromboticandthrombolytictherapy.8thed:ACCPguidelines.pharmacologyandmanagementofthevitaminKantagonists.Chest2008;33(6):160S–98S.13. read more..

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    218CHAPTER9InfECTIousDIsEAsEs1. Answer: AThe rationale for clearance antibiotics after an individual case of invasive meningococcal disease is to prevent secondary cases. Antibiotics are used to eliminate carriage in the asymptomatic carrier who was responsible for transmission of the meningococcus to the index case, therefore preventing transmission to other susceptible individuals in the carrier’s close contact network. Clearance antibiotics are therefore indicated for the following contacts read more..

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    AnsWERs219Cultures are positive in 1–40% of patients with CAP but only change management in 1 in 500 patients. Anaerobic cultures are not warranted in patients with CAP, and should be reserved for patients with suspected abdominal and pelvic sources of infection. The most common organism isolated on culture in patients with CAP is Streptococcus pneumoniaeactionGoTo:243,.44. Answer: DThis patient’s examination and X-ray findings are consistent with severe pneumonia as calculated by two read more..

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    220CHAPTER9InfECTIousDIsEAsEs7. Answer: CYellow fever is caused by Flavivirus infection transmitted by a mosquito and is endemic in parts of South America and Africa. Vaccination is mandatory prior to entering endemic areas; it is also highly effective, hence the infection is rare in travellers. Symptoms develop after an incubation period of 3–6 days and vary in severity from a flu-like illness to haemorrhagic fever with a 50% mortality rate. Typical symptoms include fever, headaches, read more..

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    AnsWERs221• if the procedure involved the needle being placed in an artery or vein• if the source has a terminal illnessThe prevalence of HIV among injecting drug users in Australasia is 1–2%, so the risk of HIV transmission in this case would be ~ 1 : 300 x 1 : 100 i.e. 1: 30,000. The use of PEP should be discussed with an infectious diseases clinician, and if prescribed, a 2 or 3 drug regime should be used (e.g. zidovudine plus lamivudine, and lopinavir/ritonavir); single-drug regimes read more..

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    222CHAPTER9InfECTIousDIsEAsEsTenosynovitis may affect many tendons simultaneously, and is uncommon in other infectious forms of arthritis. The rash associated with DGI usually develops on the extensor surfaces of the wrists, palm and hands, as well as the dorsal aspects of the ankles and feet. Diagnosis is made on clinical findings plus skin, synovial, blood and cervical/urethral cultures, although these may be negative. Treatment involves parenteral antibiotics (ceftriaxone due to penicillin read more..

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    AnsWERs223meningitis or encephalitis, although the latter is not preceded by known herpes infection in 80% of cases.The mainstay of therapy is providing adequate analgesia and to ensure oral rehydration. Oral aciclovir may reduce the length and severity of symptoms when started early in the disease and should be considered, especially in severe cases. Topical aciclovir is ineffective.Herpangina is an acute febrile illness usually affecting children in which there are ulcerated or vesicular read more..

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    224CHAPTER9InfECTIousDIsEAsEsof a new host; some patients may be asymptomatic of primary TB but others manifest a pneumonitis similar to viral infection with fever, shortness of breath and possible chest pain. After a period of latent infection organisms proliferate; the lung apices are common sites of this reactivation due to their high oxygen content and blood flow.A Mantoux test involves injection of purified protein derivative under the skin and measurement of the delayed hypersensitivity read more..

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    AnsWERs225medications should not be given at the same time as the actionGoTo:244,antibiotic.36,3720. Answer: AFood poisoning may be caused by viral (rotavirus, norovirus, astrovirus, enteric adenovirus) or bacterial pathogens. Most episodes of gastroenteritis due to food poisoning are self-limited and require only supportive care. Elderly patients, young children and the immunocompromised are more likely to have severe illness. Antibiotic therapy may be necessary in certain instances; the need read more..

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    226CHAPTER9InfECTIousDIsEAsEsNeisseria, Chlamydia trachomatis, syphilis and HSV; it causes painful defecation, rectal discharge and tenesmus; treatment is of the causative actionGoTo:244,agent.1224. Answer: CCervicitis is commonly due to Chlamydia trachomatis infection; in women, infection may be asymptomatic or be a cause of infertility; other presentations include symptoms and signs of pelvic inflammatory disease, dyspareunia and vaginal discharge or lower abdominal pain if symptoms have been read more..

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    REfEREnCEs2277. BorlandM,DunnR.Feverinchildren.In:DunnR,DilleyS,BrookesJ,editors.Theemergencymedicinemanual.5thed.Adelaide:VenomPublishing;2010.p.803–14.8. RileyLE.Varicella-zostervirusinfectioninpregnancy.In:UpToDate.Waltham:UpToDateInc;2011.Online.Available:actionURI(http://www.uptodate.com):www.uptodate.com.9. TherapeuticGuidelinesLimited.Malaria.In:eTGcomplete.Online.Available:actionURI(https://www.tg.org.au):https://www.tg.org.au;2Nov2011.10. read more..

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    228CHAPTER9InfECTIousDIsEAsEsEmergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.1062–70.39. AndrusP,JagodaA.Acuteperipheralneurologiclesions.In:TintinalliJE,StapczynskiJS,MaOJ,editors.Emergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.1159–66.40. TakharSS,MoranGJ.Disseminatedviralinfections.In:TintinalliJE,StapczynskiJS,MaOJ,editors.Emergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.1024–31.41. read more..

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    ANSWERS2291. Answer: DTypical target lesions can be seen in erythema multiforme (EM). In addition, erythematous macules and papules, vesiculaobullous lesions and urticaria may occur in this condition. In SJS similar lesions are seen but the target lesions can be atypical. In TEN vesicles and bullae are the main lesions and there is associated painful and tender erythroderma and exfoliation. Furthermore, flat atypical targets may be seen in TEN. Pyoderma gangrenosum is a dermatosis with dense read more..

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    230CHAPTER10DERmATologiCAlEmERgENCiESSimilar-looking conditions such as SJS and TEN should be considered in the differential diagnosis; skin biopsy may be required in the differentiation. The skin biopsy will show the subcorneal split in the epidermis. This means these blisters have very thin roofs and therefore break easily. There is no mucosal involvement in SSSS as opposed to what occurs in SJS/TEN. The mainstays of management of these children are intravenous fluid resuscitation similar to a read more..

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    ANSWERS231Neisseria gonorrhoea can be demonstrated with gram-staining of fluid obtained from the lesions and blood cultures often become positive in the early stages of the disease. However, the cultures remain sterile from specimen obtained from mucosal surfaces (e.g. urethral, cervical, vaginal). These should be tested for gonococcal actionGoTo:249,antigens.37. Answer: BAbout 3% of the patients admitted to hospital have been found to have rashes due to adverse drug reactions and this number read more..

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    232CHAPTER10DERmATologiCAlEmERgENCiESfaeco-oral contamination is usually the mode of spread. The incubation period is 3–5 days and then small blisters appear on palms and soles and painful ulcers appear in the oral mucosa. The lesions may be present on buttocks of some children. The first week appears to be the most contagious; however, infected children may shed the virus in the faeces for weeks and continue to be contagious at a lower level. In addition the virus may be present in fluid of read more..

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    ANSWERS2331. Answer: CPseudohyponatraemia is hyponatraemia in the setting of normal plasma osmolality (POsm 275–295). High levels of plasma proteins and lipids increase the non-aqueous and non-Na+ containing fraction of plasma which analysers misread as a factitious lower value of [Na+] than the serum truly contains. Hence, a pseudohyponatraemia. It is also known as factitious hyponatraemia. Causes of pseudo or factitious hyponatraemia include hyperlipidaemia and hyperproteinaemic states such read more..

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    234CHAPTER11ElECTRolyTEANdACid–BASEdiSoRdERS4. Answer: AThe normal total serum calcium concentration is 2.15–2.55 mmol/L, and hypercalcaemia can be defined as a level higher than this. It is a relatively common condition with more than 90% of causes being attributed to hyperparathyroidism or malignancy. Treatment should be initiated in any symptomatic patient or if the [Ca2+] is >3.5 mmol/L. There are four primary treatment goals:1. hydration2. enhancement of renal excretion of calcium3. read more..

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    ANSWERS235calculated as the ratio of the change in AG to the change in [HCO3−]. It can be used in the presence of a high AG metabolic acidosis to further evaluate for a coexistent metabolic abnormality. In a pure high AG metabolic acidosis the rise in the AG equals the fall in bicarbonate and there is a 1 : 1 relationship between the AG and the fall in bicarbonate. If the rise in the AG is less than the fall of the bicarbonate then a mixed high AG and normal AG metabolic acidosis coexist. If read more..

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    236CHAPTER11ElECTRolyTEANdACid–BASEdiSoRdERS(chloride responsive metabolic alkalosis). Urinary chloride is usually <10 mmol/L. Alternatively, other conditions causing mineralocorticoid excess, such as Conn’s syndrome, Cushing’s syndrome, adrenal hyperplasia and renal artery stenosis also produce a state of hyperaldosteronism, which also leads to a metabolic alkalosis and hypokalaemia. In these conditions, however, the extracellular volume is expanded and patients may often be read more..

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    ANSWERS23715. Answer: CThe treatment of metabolic acidosis should be directed at treating the primary cause and the use of intravenous bicarbonate therapy should be reserved only for a few cases. These indications include:• poisonings – TCAs, salicylates (alkalinising the urine promotes salicylate diuresis and renal clearance), cyanide, toxic alcohols• cardiac arrest – in young children or pregnant women• severe hyperkalaemia with cardiac toxicity (though calcium gluconate will more read more..

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    238CHAPTER11ElECTRolyTEANdACid–BASEdiSoRdERSKeeping this in mind, working through each of the above blood gas pictures:A. Acidaemia with a respiratory acidosis. Expected HCO3 can be calculated to beHCO3 = 24 +{[CO2] – 40}/10 i.e. ~27, therefore single acid–base disturbance.Hypokalaemia as expected, hence answer A is correct.B. Acidaemia with respiratory acidosis. Expected HCO3 calculated as 27. Hyperkalaemia however, is not typically expected, hence answer B is incorrect.C. Alkalaemia with read more..

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    ANSWERS239correction of sodium at a faster rate than what the brain can adapt to at the higher osmolality. Demyelination is seen in the pontine and extrapontine sites on MRI. There is an increased risk of developing CPM if the hyponatraemia has been present for >48 hours. Additionally, alcoholics, malnourished and elderly patients are more susceptible to the disease. CPM is characterised by neurological findings such as fluctuating level of consciousness, mutism, dysphagia, dysarthria, read more..

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    240CHAPTER11ElECTRolyTEANdACid–BASEdiSoRdERSthe primary process with a secondary respiratory acidosis.The AG is calculated to be 144 – [98 + 15] = 31 (i.e. elevated). The delta gap can also be calculated as 31 – 12/ 24–15 = 2.1, thereby also indicating a coexistent process to the high anion metabolic acidosis.References1. read more..

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    ANSWERS2411.  Answer: BSellick’s manoeuvre, in which an assistant applies cricoid pressure during intubation to prevent aspiration, may worsen the laryngoscopic view. All of the remaining manoeuvres are associated with improved visualisation of the vocal cords but it appears that read more..

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    242CHAPTER12EmERgENCyANAESTHESiAANdPAiNmANAgEmENTto induction agents, there is consistent evidence from the literature to guide the dosing of neuromuscular blocking agents. Suxamethonium should be dosed according to total body weight as dosing based on ideal body weight provides inadequate paralysis and poorer laryngoscopic views. Non-depolarising neuromuscular blocking agents such as vecuronium and rocuronium should be dosed according to ideal body read more..

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    ANSWERS243response. A clinically significant hyperkalaemic response can occur ≥5 days after a burn, denervation or crush injury due to acetylcholine receptor upregulation at the neuromuscular junction with resultant exaggerated hyperkalaemic response. Similarly, patients with pre-existing myopathies, myasthenia gravis and pre-existing hyperkalaemia are also at risk and suxamethonium should be avoided in this population.Fasciculations and muscle read more..

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    244CHAPTER12EmERgENCyANAESTHESiAANdPAiNmANAgEmENTresuscitation is more difficult after bupivacaine-induced cardiovascular collapse, and acidosis and hypoxia markedly potentiate the actionGoTo:265,cardiotoxicity.17,19,2111.  Answer: BPrilocaine is the drug of choice for intravenous regional anaesthesia because it is the least toxic local anaesthetic agent. It can safely be given at a dose of 2.5 mg/kg (0.5 mL/kg of a 0.5% solution). Prilocaine should be injected slowly over 90 seconds. read more..

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    ANSWERS245and has a number of significant disadvantages. Accumulation of the active metabolite, norpethidine can cause hyperexcitability, tremors, myoclonus and seizures, especially with repeated dosing or renal impairment. In addition, pethidine can cause serotonin syndrome when combined with other serotonergic medication and has a higher potential for abuse. It is now highly recommended that pethidine should be actionGoTo:265,avoided.28–3314.  Answer: DMidazolam has anxiolytic, sedative read more..

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    246CHAPTER12EmERgENCyANAESTHESiAANdPAiNmANAgEmENTI Normal healthy patientII Patient with mild systemic conditionIII Patient with a severe systemic condition that limits activity but is not incapacitatingIV Patient with an incapacitating systemic condition that is a constant threat to lifeV Moribund patient not expected to survive for 24 hoursChildren should be adequately prepared for any procedure in the ED. This entails some forethought on the part of the administrators of the ED, as a read more..

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    ANSWERS247procedures. What is important is how they behave in a given situation. Adult behaviours likely to interfere with a child’s coping include:• making reassuring comments (e.g. ‘It’ll be all right’)• apologising (e.g. ‘I’m sorry you have to go through this’)• criticising (e.g. ‘You’re being a baby’)• bargaining with the child (e.g. ‘I’ll get you a play station if you let them do it’)• giving the child control over when to start the procedure (e.g. read more..

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    248CHAPTER12EmERgENCyANAESTHESiAANdPAiNmANAgEmENTReferences1. VissersRJ,DanzlDF.Trachealintubationandmechanicalventilation.In:TintinalliJE,StapczynskiJS,MaOJ,editors.Emergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.198–209.2. HendersonJJ.Directlaryngoscopyandoralintubationofthetrachea.In:HungO,MurphyMF,editors.Managementofthedifficultandfailedairway.NewYork:McGrawHill;2007.p.103–21.3. read more..

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    REFERENCES24934. GreenSM,RoabackMG,KennedyRM,etal.Clinicalpracticeguidelineforemergencydepartmentketaminedissociativesedation:2011update.AnnEmergMed2011;57(5):449–61.35. MinerJ.Proceduralsedationandanalgesia.In:TintinalliJE,StapczynskiJS,MaOJ,editors.Emergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.283–91.36. read more..

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    250CHAPTER13TRAumAAndBuRns1. Answer: DChildren are a diverse group of people and vary enormously in weight, size, shape, intellectual ability and emotional responses. The larynx is situated anteriorly and superiorly at the level of C2–C3, making intubation in children difficult. The child relies on the diaphragm for breathing with the horizontal ribs hardly contributing. The infant has a greater metabolic rate and oxygen consumption and accounts for the higher respiratory rate of infants. read more..

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    AnsWERs251intracranial injury above the level of midbrain. Here, the arms are held in flexion and internal rotation while the legs are in extension.actionGoTo:282,86. Answer: COne of the aims of ED resuscitation of a severe traumatic brain injury patient is to prevent any secondary insults to the brain. Secondary insults are the clinical conditions that may worsen the outcomes of traumatic brain injury (TBI). These differ from secondary brain injury, which are changes that occur at a cellular read more..

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    252CHAPTER13TRAumAAndBuRns9. Answer: DAlthough traumatic subarachnoid haemorrhage is common in TBI, this can be missed on early CT scan done within the first 6–8 hours from the time of injury. It carries a very high mortality and risk of significant permanent neurological injury. Mortality from an acute subdural haematoma is nearly three times higher than mortality from an extradural haematoma (75% vs 20–30%). This may be related to the significant neuronal injury that is often associated read more..

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    AnsWERs253lumbosacral plexus, the sacral plexus, and the sympathetic and parasympathetic chains. Several classification systems exist to help predict the neurological deficits and establish treatment protocols. The Denis three-zone classification system is based on fracture anatomy. Zone-I fractures occur lateral to the sacral foramina and are the most common fracture pattern. Neurological injury occurs in approximately 6% of patients and typically involves the L4 and L5 nerve roots. Zone-II read more..

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    254CHAPTER13TRAumAAndBuRnsbelow the level of the lesion including that of bladder and bowel occurs in spinal shock. Priapism is an associated feature in some patients. When spinal shock resolves, the bulbocavernous reflex usually returns first.In contrast, the neurogenic shock is secondary to peripheral sympathetic denervation due to cord injury at cervical or thoracic levels. The neurogenic shock is manifested by a triad of hypotension, bradycardia and hypothermia. The sympathetic denervation read more..

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    AnsWERs255primary survey. Early control of posterior and anterior epistaxis with balloon devices can be attempted, with care not to place the balloon device intracranially through the fracture. For very severe oral bleeding the use of two suction devices are often needed. Two-person bag–valve–mask (BVM) ventilation is often required in the airway management. This should be done with skilled expertise and a definitive plan in hand to manage a difficult airway. Oral packing to control bleeding read more..

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    256CHAPTER13TRAumAAndBuRns21. Answer: DHanging occurs when pressure is exerted on the neck and then tightened by the weight of the victim’s body. Complete hanging refers to when the body is suspended but the feet do not touch the ground. Incomplete hanging refers to all other positions of the body, when the feet are in contact with the ground.The mechanism of death usually differs depending on the method of hanging. When a victim falls from a height equal or greater than his or her height and read more..

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    AnsWERs257placed to prevent development of a tension pneumothorax. Stab wounds to the chest are notorious for producing delayed onset pneumothoraces, usually 4–6 hours from the time of injury. Therefore, when the initial CXR is negative for a pneumothorax and the patient is asymptomatic, the patient should be observed and the CXR repeated in 4–6 hours. When there is airflow obstruction as in COPD, it is more likely that more air will be pushed in to the traumatic pneumothorax form the read more..

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    258CHAPTER13TRAumAAndBuRnsMyocardial cell necrosis in myocardial contusion releases troponin; however, this happens at a relatively low level when compared with acute myocardial infarction. The sensitivity of troponin as a lone test to detect blunt myocardial injury seems to be limited (12–23%). When troponin is elevated, in combination with ECG abnormalities, it indicates a high-risk patient. These patients should be cardiac monitored in an inpatient setting with further investigation with read more..

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    AnsWERs25931. Answer: BAortic injuries are usually associated with high kinetic energy injuries. The mechanism of injury is such that as much as 75% of patients have fractures of bones other than the ribs. Traumatic rupture of the aorta begins in the intima and moves outwards into the adventitia, which provides most of the tensile support. The atherosclerosis in the tunica media does not predispose the aorta to traumatic rupture. Approximately two-thirds of the tears start at the isthmus of the read more..

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    260CHAPTER13TRAumAAndBuRnsshock due to late sudden rapid bleeding if not detected early. Children tend to be more haemodynamically stable than adults for the same degree of splenic injury. Therefore, children are more likely to be managed conservatively and the vast majority of children recover fully with conservative management. A fatal haemorrhage is more likely to be associated with a liver injury than a splenic injury. Haemodynamically stable liver injuries are often managed conservatively read more..

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    AnsWERs261exsanguinating haemorrhage. In these patients, all measures such as application of pelvic binding or C-clamp should be done to reduce the pelvic volume and increase the tamponading effect in order to slow the bleeding. The following steps are generally applicable to this actionGoTo:283,scenario.43• FAST scan should be the first bedside investigation.• If FAST is grossly positive, laparotomy is indicated prior to consideration for pelvic angiography, external fixation or surgical read more..

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    262CHAPTER13TRAumAAndBuRns41. Answer: BFetal distress on CTG, which predicts underlying occult maternal placental bleeding, is characterised by:• an abnormal baseline heart rate (<120 or >160 bpm)• a decreased beat-to-beat and long-term variability• decelerations of the heart rate after uterine contractions.The Kleihauer test needs at least 5 mL of fetomaternal haemorrhage for it to be positive. This means that the need for RhIg (or anti-D) should not be based on this test. Any Rh read more..

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    AnsWERs263• primary blast injury – injuries due to direct barotrauma to organs by over pressurisation or under pressurisation• secondary blast injury – due to penetrating trauma by fragments of the bomb as well as those that result from the explosion• tertiary blast injury – due to structural collapse and blunt trauma due to patient being thrown by the blast wind• quaternary blast injury – due to burns, asphyxia and exposure to toxic inhalants.actionGoTo:283,4945. Answer: AThe read more..

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    264CHAPTER13TRAumAAndBuRnsnature. The aim of DCR is to avoid the ‘lethal triad’ of hypothermia, coagulopathy and metabolic acidosis, which is made worse with the injudicious use of crystalloid.The components of DCR include:• haemostatic resuscitation with a use of a massive transfusion protocol (e.g. early transfusion of PRBCs, FFP and platelets in the ratio of 1 : 1 : 1)• restriction of crystalloids• systolic blood pressure is ideally maintained between 80–100 mm Hg until bleeding read more..

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    REFEREnCEs265References1. Mackway-JonesK,MolyneuxE,PhillipsB,editors.Advancedpaediatriclifesupport:thepracticalapproach.4thed.Whytreatchildrendifferently?Oxford:BlackwellPublishing;2005.p.7–14.2. Mackway-JonesK,MolyneuxE,PhillipsB,editors.Advancedpaediatriclifesupport:thepracticalapproach.4thed.Thestructuredapproachtotheseriouslyinjuredchild.Oxford:BlackwellPublishingLtd;2005.p.151–66.3. read more..

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    266CHAPTER13TRAumAAndBuRnsmedicine:acomprehensivestudyguide.7thed.NewYork:McGrawHillMedical;2011.p.1758–65.34. EmbreyR.Cardiactrauma.ThoracSurgClin2007;17:87–93.35. DunnR.Penetratingtrauma.In:DunnR,DilleyS,BrookesJ,editors.Theemergencymedicinemanual.5thed.Adelaide:VenomPublishing;2010.p.1197–210.36. DemetriadesD,VelmahosGC.Penetratinginjuriesofthechest:indicationsforoperation.ScandinavianJournalofSurgery2002;91:41–5.37. read more..

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    ANSWERS2671. Answer: CIn Salter-Harris type I injuries the fracture goes through the growth plate, completely separating the epiphysis from the metaphysis. However, the epiphysis is not always displaced, hence there may not be any abnormalities visible on X-ray. The epiphysis is displaced when the periosteum is damaged or torn. Usually the displaced epiphysis is easily reduced as the two surfaces are covered with cartilage.In Salter-Harris type V injury, the growth plate is crushed, all or in read more..

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    268CHAPTER14ORTHOPAEdiCEmERgENCiESWhen assessing these movements it is important to provide the child with adequate analgesia first, but any deficit should not be attributed to the presence of pain.actionGoTo:296,34. Answer: CGartland classification of extension type (98%) supracondylar fractures:• Gartland type I: undisplaced – fracture line may or may not be visible on AP and lateral views; an effusion can usually be recognised on X-ray• Gartland type IIa: posterior angulation with read more..

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    ANSWERS269displacement there is marked swelling over the lateral elbow both clinically and on X-ray. The lateral view may show the fracture line more clearly, but oblique views are considered the best to determine the degree of displacement and rotation. Multiple oblique views may be needed to accurately differentiate a non-displaced fracture from a displaced one.A truly non-displaced fracture or fracture that is truly <2 mm displaced (minimal lateral elbow swelling) can be treated with cast read more..

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    270CHAPTER14ORTHOPAEdiCEmERgENCiESinoculation to the hip joint may occur during less careful femoral venous access in children. Osteomyelitis in children occur characteristically in the metaphysis of long bones, especially in femur, tibia and humerus. Brodie abscess is a form of subacute pyogenic osteomyelitis usually affecting the metaphysis of long bones or metaphyseal equivalent bones (tarsal and carpal bones, pelvis and vertebrae) mainly in children.In acute septic arthritis, plain X-ray is read more..

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    ANSWERS27113. Answer: BThe sternoclavicular joint is the most frequently mobile non-axial joint of the body. It is one of the most stable joints because it is strengthened by the surrounding strong ligaments. Consequently, dislocations are rare unless a high degree of forces are involved. Similarly, fractures involving the medial (proximal) clavicle account only for 5% of all clavicular fractures. Routine clavicular X-ray may not precisely show the fracture and dislocations in this area. read more..

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    272CHAPTER14ORTHOPAEdiCEmERgENCiESin post-reduction X-rays. The following abnormalities should be properly actionGoTo:297,corrected.18• Dorsal tilt (on lateral view): should be reduced if the tilt is >neutral. Some allow up to 10 degrees of dorsal tilt.• Radial shortening (on PA view): loss of 2 mm or more should be corrected (normally radial styloid extends 9–12 mm beyond articular surface of distal ulna).• Radial shift (on PA view): any shift should be corrected.• Radial read more..

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    ANSWERS273replantation. All other conditions mentioned are definitive indications for referral for replantation. If the digit is partially amputated and still attached to the proximal stump, surgical re-attachment is called revascularisation.actionGoTo:297,22,2320. Answer: BCompartment syndrome may occur due to a variety of causes but is most commonly due to fractures of the tibia (40% of the cases) and forearm. Other conditions such as haemorrhage, oedema secondary to ischaemic reperfusion read more..

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    274CHAPTER14ORTHOPAEdiCEmERgENCiES23. Answer: AThis is a relatively frequent scenario where an elderly patient presenting to the ED with hip pain and inability to fully weight-bear but has normal-appearing pelvic and hip radiography. In this scenario, a thorough examination is necessary to exclude other possible injuries such as a missed femoral shaft fracture. Hip radiographs should be examined for subtle signs of a nondisplaced neck of femur fracture. These subtle signs of a nondisplaced read more..

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    ANSWERS275haemarthroses are due to ACL injuries. Haemarthrosis can also be caused by peripheral meniscal tears and intraarticular fractures.• A cruciate ligament injury may present without haemarthrosis and even without much pain. This usually occurs when there is disruption to the capsule, causing a leakage of blood into the surrounding soft tissues.• A Segond fracture (an avulsion fracture on the lateral tibial condyle at the site of attachment of the lateral capsular ligament) indicates read more..

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    276CHAPTER14ORTHOPAEdiCEmERgENCiES• Bone overlap between the distal tibia and fibula should be at least 10 actionGoTo:297,mm.3430. Answer: BIn the diagnosis of Achilles tendon rupture the following may be helpful:• Thompson test: On a prone patient with feet extending over the edge of the examination bed, squeezing the calf muscles should cause plantar flexion when the tendon is intact.• Hyperdorsiflexion sign: On a prone patient with their knees kept at 90 degrees, the examiner passively read more..

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    ANSWERS277an axial load. The injury spectrum consists of sprains to the Lisfranc’s ligament to complete disruption to the midfoot with displacement and fractures. The very high strength Lisfranc’s ligament runs between medial cuneiform and the base of the second metatarsal, and the disruption of this ligament is inevitable in significant injuries. Consequently, bony diastasis between the first and second metatarsal bases occurs and if this diastasis is ≥1 mm it should be considered an read more..

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    278CHAPTER14ORTHOPAEdiCEmERgENCiESto the lumbosacral region and is not associated with radicular pain (sciatica). Most patients have no identifiable abnormailites, even with radiological imaging. Therefore imaging of these patients is unlikely to be helpful unless red flag features are present. The causes include:• muscular and ligamentous sprain due to trauma to the lumbar spine• facet joint sprain• internal disruption of the annulus fibrosus of the disk (without herniation of nucleus read more..

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    REFERENCES279ED management includes analgesia and orthopaediac referral for outpatient follow-up or admission for patients with disabling symptoms.actionGoTo:297,41,4239. Answer: DAlthough septic arthritis of interphalangeal joints cannot be excluded in this patient, it is more likely that this patient has flexor tendon sheath infection (infectious flexor tenosynovitis) secondary to direct inoculation of the organisms during the injury. The most common organism involved is Staphylococcus aureus read more..

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    280CHAPTER14ORTHOPAEdiCEmERgENCiES11. LalondeF,WengerD.Tibia.In:RangM,WengerD,PringM,editors.Rang’schildren’sfractures.3rded.Philadelphia:LippincottWilliams&Wilkins;2005.p.215–26.12. CordleR,CanterR.Pediatrictrauma.In:MarxJ,HockbergerR,WallsR,etal,editors.Rosen’semergencymedicine:conceptsandclinicalpractice.7thed.MosbyElsevier;2009.p.262–80.13. read more..

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    ANSWERS2811. Answer: AIn retrocaecal appendicitis the pain may be localised to the flank. Pregnant women with appendicitis may present with right flank or right upper quadrant pain as the gravid uterus may displace the appendix. In males acute appendicitis can present with testicular pain if the appendix lies in a retroileal position. Appendicitis can also cause suprapubic pain and the sensation of the need to defaecate if the appendix lies in the pelvis.• Rovsing sign: pain in the right iliac read more..

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    282CHAPTER15SuRgiCALEMERgENCiESis out of keeping with the physical findings on examination and often refractory to analgesia. The WCC may be normal initially; however, it usually rises to >15,000 cells/mm3. Elevated lactate is a late sign and if it remains within normal limits then another diagnosis should be sought. Metabolic acidosis is a non-specific late sign. Often the abdominal X-ray is normal; however, the following features if present suggest the diagnosis of acute mesenteric read more..

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    ANSWERS283(90% cases). Tumours, malignant or benign are responsible for 65% of adult intussusceptions.Obturator hernia is an uncommon cause of SBO in adults. It is frequently diagnosed when it causes SBO.actionGoTo:314,14,156. Answer: BHernias or adhesions rarely cause large bowel obstructions. The most common reason for large bowel obstruction is colorectal cancer. Following neoplasms, diverticulitis and sigmoid volvulus are the next most common causes. Diverticulitis can cause mesenteric read more..

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    284CHAPTER15SuRgiCALEMERgENCiES9. Answer: CAn aortoenteric fistula is formed when an aortic aneurysm erodes into the gastrointestinal tract. When this occurs between the aorta and the duodenum, gastrointestinal haemorrhage can occur. It can present with back pain or signs of intraperitoneal infection. If a patient over the age of 50 with a history of AAA presents with gastrointestinal bleeding, then aortoenteric fistula should be considered as a cause.The size of the aortic diameter is the read more..

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    ANSWERS285generally experiences pain in the right lower quadrant. If the patient presents with right flank pain then a retrocaecal appendix, pyelonephritis or renal colic should be suspected.Laboratory investigations are not helpful in making the diagnosis of appendicitis in a pregnant patient because leukocytosis is frequently seen in normal pregnancies. Radiological imaging can assist in the diagnosis. Ultrasound seems to be as sensitive and specific in the pregnant population and is the read more..

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    286CHAPTER15SuRgiCALEMERgENCiESinfarction tends to present with vagal symptoms such as nausea, vomiting, abdominal pain, diaphoresis and bradycardia.actionGoTo:315,32–3414. Answer: BAcalculous cholecystitis occurs in approximately 10% of cases. Acalculous cholecystitis is thought to be due to ischaemia. Predisposing factors include:• postoperatively following major surgical procedures• major trauma• severe burns• sepsis with hypotension and multi-organ failure• intensive care read more..

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    ANSWERS287The criteria for gallstone-related pancreatitis varies slightly (see actionGoTo:304,Table 15.3).Another system that can be used for predicting the severity of pancreatitis is the Glasgow and Modified Glasgow criteria. These have been validated for gallstone and alcoholic associated pancreatitis (see actionGoTo:304,Table 15.4).The Modified Glasgow criteria can be remembered by the following pneumonic.PANCREASPaO2 < 60 mmHgAge > 55 yearsNeutrophils, WCC > 15Calcium < 2 read more..

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    288CHAPTER15SuRgiCALEMERgENCiESand occur more frequently on the right side due to the later decent of the right testis. The hernia passes through the inguinal canal and into the scrotum as it enlarges. Complications are frequent particularly in females and infants. Around 5% of term and 30% of preterm infants will have an inguinal hernia. Surgery is recommended, if they are symptomatic or complications actionGoTo:314,arise.3,43,4419. Answer: DIndications for attempting to reduce a hernia are read more..

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    ANSWERS28922. Answer: ABoerhaave’s syndrome is a transmural oesophageal rupture that results from sudden raised intraluminal pressure caused by uncoordinated vomiting with the pylorus and cricopharyngeus closed. In the majority of cases it occurs secondary to this forceful emesis. Less commonly Boerhaave’s syndrome can occur as a result of coughing, straining, seizures or during labour. The most common location for the rupture to occur is the left lower posteriolateral wall of the read more..

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    290CHAPTER15SuRgiCALEMERgENCiESmovement of the wrist. Time taken to develop compartment syndrome is variable.Tissue loss, rhabdomyolysis and renal failure are also recognised complications of inadvertent intraarterial injection.The presentation is not consistent with deep vein thrombosis (DVT). DVT would be more likely to present with a red warm swollen arm and tenderness to palpation along the deep veins.There are similarities to an acute ischaemic limb; however, this diagnosis is excluded as read more..

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    ANSWERS291good as angiography if the operator is experienced. However, though accessibility is on the increase it can still be limited. As this investigation is invasive and sedation is necessary, it can be unsuitable in unintubated unstable patients.DeBakey I (ascending, aortic arch and descending aorta) and II (ascending aorta) or Stanford type A (DeBakey I and II, proximal aorta and varying length of descending aorta) proximal dissections require surgical intervention.Patients with distal read more..

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    292CHAPTER15SuRgiCALEMERgENCiES• cephalexin 500 mg orally, 6-hourly for 5 days can be used if the patient has a penicillin allergy• clindamycin 450 mg orally, 8-hourly for at least 5 days can be used if the patient has severe penicillin hypersensitivity.If the patient has severe infection, cellulitis or signs of sepsis then intravenous antibiotics should be administered.Co-amoxiclav or a macrolide can also be used to treat lactating infection. Tetracyclines, ciprofloxacin and chloramphenicol read more..

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    ANSWERS293time since the injury and the extent of the injury, it is important also to consider the patient’s mobility, medications, level of independence and comorbidities, as these effect wound healing.It is advisable not to suture pretibial lacerations. Where possible skin edges should be gently apposed and Steri-strips applied with a non-adherent dressing. It is essential that the wound is not placed under any tension as this increases the chance of necrosis and delayed wound healing. If read more..

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    294CHAPTER15SuRgiCALEMERgENCiEStraumatic lumbar puncture because this blood has not been exposed to and broken down by the CSF enzymes.Nimodipine 60 mg 4-hourly should be administered orally for 7 days. It has been shown to decrease the incidence of vasospasm, prevent secondary ischaemia and reduce the mortality associated with actionGoTo:316,SAH.76–8034. Answer: DThis patient most likely has malrotation with volvulus. It is a life-threatening condition. In this case there is a strong read more..

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    ANSWERS295for approximately 95% of cases. Features of this enzyme deficiency are related to androgen excess.It presents as masculinisation of females and can range from ambiguous genitalia and pseudohermaphroditism in infants to oligomenorrhoea, hirsutism and acne in postpubertal females. In males it can cause enlarged external genitalia and precocious puberty.Severe enzyme deficiency can be life threatening, presenting with vomiting, severe dehydration, electrolyte abnormalities (severe read more..

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    296CHAPTER15SuRgiCALEMERgENCiESdepending on the site and how rapid the bleeding is. The highly acidic gastric tissue in the diverticulum causes ulcerations that bleed. If the diverticulum contains pancreatic tissue, ulcerations and bleeding can result from the alkaline envirnment. Bleeding is usually self-limiting because the splanchnic vessels constrict secondary to hypovolaemia. Anaemia is usually transient. Meckel’s diverticulum can be a lead point for intussusception and can present as read more..

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    REFERENCES297Children are more likely to have a foreign body stuck at the level of the cricopharyngeus muscle, adults more frequently at the level of the lower oesophageal sphincter.actionGoTo:317,98–10140. Answer: DCervical lymphadenitis is the most likely diagnosis in this child. However, other differentials that should be considered include:• Reactive lymph node secondary to a viral infection – this is unlikely in this case as reactive lymph nodes are generally small, firm and read more..

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    298CHAPTER15SuRgiCALEMERgENCiESimmunocompromisedandpregnantpatients.EmergencyMedicineReport2004;25(23).Online.Available:actionURI(http://www.EMRonline.com):www.actionURI(http://www.EMRonline.com):EMRonline.com.16. VicarioSJ,PriceTG.Bowelobstructionandvolvulus.In:TintinalliJE,StapczynskiJS,MaOJ,eds.Emergencymedicineacomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.581–317. read more..

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    REFERENCES299emergencymedicine.7thed.Philadelphia:MosbyElsevier;2010.p.456–66.49. DilleyS,DunnR.Vascularemergencies.In:DunnR,DilleySJ,BrookesJG,etal,editors.Theemergencymedicinemanual.5thed.Adelaide:VenomPublishing;2010.p.479–86.50. KhanAZ,StraussD,MasonRC.Boerhaave’ssyndrome:diagnosisandsurgicalmanagement.Surgeon2010;5(1):39–44.51. read more..

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    300CHAPTER15SuRgiCALEMERgENCiES83. HostetlerMA.Gastrointestinaldisorders.In:MarxJA,HockbergerRS,WallsRM,etal,editors.Rosen’semergencymedicine,7thed.Philadelphia:MosbyElsevier;2010.p.2168–87.84. KennedyM,LiacourasCA.Malrotation.In:KliegmanRM,StantonBF,SchorNF,editors.Nelsontextbookofpediatrics.19thed,Philadelphia:SaundersElsevier;2011.p.1280–1.85. read more..

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    ANSWERS301keratoconjunctivitis. Slit lamp examination shows a diffuse superficial keratitis without corneal ulceration.Slit lamp examination is important during examination of the eye; the cornea should be viewed with fluoresceine staining to exclude dendritic ulcers caused by herpes simplex virus (HSV). However, this is a challenging but necessary examination in children. The diagnoses of conjunctivitis is clinical and appropriate swabs for bacterial culture and viral studies should only be read more..

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    302CHAPTER16EyE,ENTANddENTAlEmERgENCiESorbital rim it prevents the swelling to spread to the upper eyebrow and eyelid in orbital cellulitis.• In orbital cellulitis reduced visual acuity, proptosis, chemosis and abnormal pupillary response are present, whereas in periorbital cellulitis the visual acuity and pupillary reactions are preserved.• Patients are more likely to be systemically unwell in orbital cellulitis.The organisms involved in orbital cellulitis are respiratory pathogens (S. read more..

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    ANSWERS303affecting the optic nerve and a large proportion of these patients develop multiple sclerosis subsequently. Other causes include viral infections (measles, mumps, varicella, Epstein-Barr virus), bacterial infections (tuberculosis, cryptococcus, syphilis), sarcoidosis, post vaccination in children, and idiopathic. Eye pain with eye movements and afferent pupillary defect are typical features in optic neuritis. Visual acuity in the affected eye could be greatly decreased and colour read more..

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    304CHAPTER16EyE,ENTANddENTAlEmERgENCiESIsolated third nerve palsy can be classified based on ‘the rule of the pupil’:• A pupil involving third nerve palsy is usually secondary to a compressive lesion such as posterior communicating artery aneurysm or basilar tip aneurysm. The anatomic basis for the pupillary involvement is the arrangement of the pupillary constrictor fibres superficially on the dorsomedial aspect of the nerve when it runs through the subarachnoid space. These fibres can read more..

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    ANSWERS30513. Answer: CPatients might occasionally present to the ED with signs of retrobulbar haemorrhage following a severe degree of blunt trauma to the orbit. Patients on anticoagulant therapy may present in a similar way. The orbit can be an uncompromising soft tissue space due to the presence of the globe in the front and the firm attachments of the eyelids to the orbital rim with the lateral and medial canthal ligaments. As a result, undisplaced orbital fractures are more commonly read more..

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    306CHAPTER16EyE,ENTANddENTAlEmERgENCiESdevice should then be retracted anteriorly to provide the tamponade in the choanae and sphenopalatine foramen actionGoTo:326,areas.11,1216. Answer: CA peritonsillar abscess is formed secondary to an infection in the mucous salivary glands located superior to the tonsils in the soft palate. With infection, peritonsillar cellulitis develops in the soft palate and later pus formation occurs with the development of an abscess. It is a polymicrobial infection; read more..

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    ANSWERS307management of nasal fractures and CT scans are unnecessary.Nasal fractures are often reduced under general anaesthetic and that should be done very early (within 4 days) to overcome the faster fracture healing time in children.actionGoTo:326,1220. Answer: DMalignant otitis externa is a less common but potentially life-threatening form of otitis externa. The presence of diabetes and immunosuppression increases the risk of having this condition. In >90% of patients the causative read more..

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    308CHAPTER16EyE,ENTANddENTAlEmERgENCiESfascia running between the under surface of the mandible and hyoid bone. The mucous membrane of the floor of the mouth forms the roof of the submandibular space. The non-distensible nature of the investing layer of deep cervical fascia causes any swelling in the submandibular space to upwardly displace the floor of the mouth and tongue, compromising the airway.Any attempt at obtaining a CT without thoroughly evaluating and securing the airway where read more..

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    REFERENCES309References1. DuongD,LeoM,MitchellE.Neuro-ophthalmology.EmergMedClinNAm2008;26:137–80.2. WalkerR,AdhikariS.Eyeemergencies.In:TintinalliJE,StapczynskiJS,MaOJ,editors.Emergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGraw-Hill;2011.p.1517–49.3. PrentissK,DorfmanD.Pediatricophthalmologyintheemergencydepartment.EmergMedClinNAm2008;26:181–98.4. MahmoodA,NarangA.Diagnosisandmanagementoftheacuteredeye.EmergMedClinNAm2008;26:35–55.5. read more..

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    310CHAPTER17URologiCAlEmERgEnCiEs1. Answer: CAlthough no minimal bladder volume has been determined, a poorly defined bladder is a contraindication for SPC insertion. A history of lower abdominal surgery, intraperitoneal surgery or irradiation places the patient at increased risk of complications such as bowel injury because they may result in adherence of the bowel to the bladder wall. Other contraindications to percutaneous insertion include coagulopathies and pelvic trauma; however, SPC via read more..

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    AnsWERs311pregnant or had a chronic illness and a unilateral functioning kidney.Torsion of the testicular appendage is a common cause of testicular pain in the 7–14-year age group. Onset is gradual, usually over 1–2 days, and the patient is still able to ambulate as normal. On examination the affected testicle itself is non-tender, of normal size and normal lie, and there is maximal tenderness at the upper pole of the testis. A small, hard, tender nodule may be palpated at the upper pole of read more..

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    312CHAPTER17URologiCAlEmERgEnCiEsTable17.1gRADingoFREnAlTRAUmAGradeDescriptionTreatmentIContusion, microscopic or gross haematuria, urological investigations normalSubcapsular non-expanding haematoma without lacerationObservationSpontaneous resolutionIIParenchymal laceration < 1 cm depth of renal cortexNo extravasation of collecting system injuryNon-expanding haematoma, confined to retroperitoneumObservationSpontaneous resolutionIIIParenchymal laceration > 1 cm depth of renal cortex with read more..

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    AnsWERs313chances of testis survival at 24 hours is near zero. Ideally, the patient should undergo surgery within 6 hours of symptom onset.Doppler USS can produce both false positives and negatives. Even the torted testis can demonstrate intra-testicular blood flow on Doppler USS, which can be misleading and lead to an incorrect diagnosis. It has only 80% sensitivity for diagnosis of testicular torsion.actionGoTo:332,7,9,12,209. Answer: DAbdominal aortic aneurysm and renal colic can cause read more..

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    314CHAPTER17URologiCAlEmERgEnCiEs• nitrites: false negative if high specific gravity (SG), low pH, specimen standing a long time prior to testing; false positive if the testing stick is exposed to air, with pyridium• ketones: false positive with levodopa, valproate, N-acetyl cysteine, high-protein diet, high SG of actionGoTo:332,urine.4,2112. Answer: BAs little as 1 mL of blood in 1L of urine can cause gross haematuria. Both microscopic and gross haematuria are caused by similar disorders. read more..

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    REFEREnCEs315depending on culture results. Nitrofurantoin is not a good choice for prostatitis because it does not penetrate the prostate and it is bacteriostatic not actionGoTo:333,bacteriocidal.2515. Answer: DUreteric stents are well tolerated by most patients; however, patients with stents often present to the ED with complications. The most common complications of these devices seen in the ED include:• stent irritation: flank and suprapubic pain, dysuria, haematuria• encrustation• read more..

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    316CHAPTER17URologiCAlEmERgEnCiEs21. DeanA,LeeD.Bedsidelaboratoryandmicrobiologicprocedures.In:RobertsJR,HedgesJR:Clinicalproceduresinemergencymedicine.5thed.Philadelphia:SaundersElsevier2009.p.1283–306.22. WolfsonAB.Renalfailure.In:MarxJ,HockbergerR,WallsR,etal,editors.Rosen’semergencymedicine:conceptsandclinicalpractice.7thed.MosbyElsevier2009.p.1257–82.23. read more..

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    ANSWERS3171. Answer: BVarious definitions for hyperemesis gravidarum (HG) exist but the important features are unexplained intractable vomiting associated with weight loss of more than 5% of pre-pregnancy weight, dehydration, electrolyte imbalances (especially hyponatraemia and hypokalaemia), ketosis and vitamin deficiencies. By far the most important serious complication of HG is Wernicke’s encephalopathy as a result of thiamine (vitamin B1) deficiency. In some cases, Wernicke’s read more..

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    318CHAPTER18ObSTETRiCANdGyNAECOlOGiCAlEmERGENCiESbut for ED purposes, all patients without a confirmed IUP (gestational sac plus yolk sac) should be regarded as an ectopic pregnancy until proven otherwise and the obstetricians should urgently be actionGoTo:344,informed.43. Answer: CMajor risk factors for ectopic pregnancy include PID, history of tubal surgery, use of an intrauterine device (IUD), assisted reproduction techniques and a previous ectopic pregnancy. However, more than 50% of cases read more..

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    ANSWERS319unknown locations (PUL) that will develop into failing PUL from intrauterine and ectopic pregnancy, particularly whenever the βHCG levels are lower than the discriminatory zone or when an ultrasound diagnosis cannot be made despite the βHCG being above the discriminatory zone. A doubling of βHCG concentrations over 48 hours is often used to predict viability but an increase of at least 66% is generally regarded as suggestive of a viable pregnancy. However, a large study published in read more..

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    320CHAPTER18ObSTETRiCANdGyNAECOlOGiCAlEmERGENCiES• external cephalic version• miscarriage or termination of pregnancyStudies have shown that Rh(D) immunoglobulin 100 IU is sufficient to protect against a FMH of 1.0 mL of fetal red cells (2.0 mL whole blood). The majority of fetal bleeds are <5 mL of red blood cells, therefore a dose of RhIG 625 IU is sufficient to protect against most cases of FMH but not all, and it is recommended that the magnitude of the FMH following a sensitising read more..

  • Page - 338

    ANSWERS321Severe preeclampsia is managed in the same way as eclampsia. The focus of treatment of severe preeclampsia is on the prevention of seizures (eclampsia) and treatment of hypertension to prevent permanent damage to maternal organs.(1) Prevention of seizures: Magnesium sulfate is given as prophylaxis against the development of eclampsia in severe preeclampsia. There is now robust evidence that, for women with severe preeclampsia, magnesium sulphate more than halves the risk of eclampsia read more..

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    322CHAPTER18ObSTETRiCANdGyNAECOlOGiCAlEmERGENCiES10 mEq/L, respiratory depression occur at 15 mEq/L and cardiac arrest at more than 15 mEq/L. This dose response relationship means that clinical monitoring should ensure that toxicity and adverse effects are avoided. For this reason, deep tendon reflexes and respiratory rate should routine be monitored and can be used as an early indicator of toxicity.Magnesium is excreted in the urine and raised serum levels will quickly occur in patients with read more..

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    ANSWERS323as the echogenicity of fresh blood is so similar to that of the placenta. Placental abruption is primarily a clinical diagnosis. Ultrasound is purely an adjunct in the diagnosis and helps exclude other causes of vaginal bleeding such as placenta praevia.actionGoTo:345,20,22,23,36,3714. Answer: AIn contrast to abruption, the classic presentation of placenta praevia is painless, bright red vaginal bleeding occurring at the end of the second trimester. Bleeding is usually painless because read more..

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    324CHAPTER18ObSTETRiCANdGyNAECOlOGiCAlEmERGENCiEScut a generous episiotomy must be based upon clinical circumstances, such as a narrow vaginal fourchette in a primigravid patient or the need to perform fetal manipulation. Draining the bladder with a Foley catheter may give more room anteriorly. Other manoeuvres include Wood’s corkscrew manoeuvre, Rubin’s manoeuvre and delivery of the posterior arm.actionGoTo:345,17,37,40–4216. Answer: CRupture of membranes that occur prior to the onset of read more..

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    ANSWERS325hominis. The most common symptom of bacterial vaginosis is an increase in a greyish white vaginal discharge. The discharge often has a fishy smell. The diagnosis of BV can be confirmed by examination of the discharge, including vaginal swab wet preparation and gram-stained smear. Typical features on examination of the discharge include:• pH >4.5 (normal vaginal pH varies between 3.8 and 4.5)• the presence of ‘clue cells’ (epithelial cells covered with small curved read more..

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    326CHAPTER18ObSTETRiCANdGyNAECOlOGiCAlEmERGENCiES21. Answer: AThere are two options for postcoital (emergency) contraception that should be given within 72 hours of unprotected sexual intercourse:1. Progestin-only method (prevents 85% of the pregnancies that would be expected from unprotected mid-cycle sexual intercourse):• single dose of levonorgestrel 1.5 mg, or• levonorgestrel 750 µg with the same dose repeated 12 hours later2. Yuzpe method (prevents 75% of pregnancies resulting from read more..

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    REFERENCES327absence of features suggesting a structural or histological uterine abnormality. The underlying pathology is a relative lack of progesterone (which is released by the corpus luteum after ovulation) to oppose the oestrogenic stimulation of the endometrium and so treatment should include progestin therapy to stabilise the endometrium.The initial treatment for most cases of abnormal uterine bleeding should be commenced in the ED. But it is important that the patient be referred for read more..

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    328CHAPTER18ObSTETRiCANdGyNAECOlOGiCAlEmERGENCiES9. GriebelCP,HalvorsenJ,GolemonTB,etal.Managementofspontaneousabortion.AmericanFamilyPhysician2005;72(7):1243–50.10. DunnR,LeachD.Pelvicpain.In:DunnR,DilleyS,BrookesJ,editors.Theemergencymedicinemanual.5thed.Adelaide:VenomPublishing;2010.p.857–63.11. SagiliH,MohamedK.Review.Pregnancyofunknownlocation:anevidence-basedapproachtomanagement.ObstetGynecol2008;10:224–30.12. read more..

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    REFERENCES32943. OyeleseY,ScorzaWE,MastroliaR,etal.Postpartumhemorrhage.ObstetGynecolClinNAm2007;34:421–41.44. ZegerW,HoltK.Gynecologicinfections.EmergMedClinNAm2003;21:631–48.45. KuhnGJ,WahlRP.Vulvovaginitis.In:TintinalliJ,StapczynskiJ,MaO,etal,editors.Tintinalli’semergencymedicine:acomprehensivestudyguide.7thed.NewYork:McGrawHillMedical;2011.p.711–6.46. read more..

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    330CHAPTER19ToxiCologyAndToxinologyToxicology1. Answer: AOnce a drug or toxin has been absorbed and has the potential to exert significant toxicity, a number of methods can be considered to enhance elimination of the drug from the body. These can be non-extracorporeal or extracorporeal methods.Non-extracorporeal methods of enhanced toxin elimination are:• MDAC (gastrointestinal dialysis)• peritoneal dialysisExtracorporeal methods of enhanced elimination are:• haemodialysis (HD)• read more..

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    AnSWERS331For carbamazepine toxicity, because of high protein binding, MDAC in combination with HP is favoured for enhanced elimination.MDAC increases clearance in the following toxicities and therefore may be useful:• carbamazepine• dapsone• phenytoin• phenobarbitone• piroxicam• theophylline• yellow oleander.After the initial dose of activated charcoal, further reduced doses are given every 2 hours for a maximum duration of 6 hours. Airway protection is generally indicated prior read more..

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    332CHAPTER19ToxiCologyAndToxinology7. Answer: AIn a patient with suspected poisoning, an increased OG is most likely to be due to the presence of unmeasured osmotically active molecules of a toxic alcohol such as acetone, methanol, ethylene glycol, isopropyl alcohol and propylene glycol. In a poisoned patient, concomitant alcohol ingestion can also cause such an increase. In addition, other non-toxicological medical conditions can cause an increased OG due to increased osmotically active read more..

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    AnSWERS33311. Answer: DInadvertent intravascular administration is the most common cause of local anaesthetic systemic toxicity. This can occur infrequently during regional nerve blocks. In addition, systemic toxicity may occur in susceptible individuals such as patients with cardiac ischaemia, conduction abnormalities or heart failure, during intravenous or intraarterial administration at therapeutic doses. CNS symptoms generally precede cardiovascular effects in toxicity. If a patient develops read more..

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    334CHAPTER19ToxiCologyAndToxinology15. Answer: BVenlafaxine and desvenlafaxine are selective serotonin and noradrenaline reuptake inhibitors (SNRI). Seizures occur in 14% of patients with venlafaxine overdose but occur in <4% in SSRI overdose and are mainly associated with citalopram. Importantly, the onset of seizures may be delayed for up to 16 hours following overdose of venlafaxine. Therefore, all patients must be observed for at least 16 hours after ingestion with intravenous access in read more..

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    AnSWERS335achieve normal renal function with good urine output and normal electrolyte balance. This enhances lithium excretion from the body. Similarly, in chronic toxicity it is important to maintain good hydration and renal function to enhance renal lithium excretion. However, enhanced elimination with haemodialysis may be necessary in the face of neurotoxicity and established renal failure.Cardiac monitoring is not indicated in lithium toxicity unless for other reasons including read more..

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    336CHAPTER19ToxiCologyAndToxinology21. Answer: DPredictors of potentially lethal acute digoxin toxicity are:• total dose ingested >10 mg in an adult (in a child >4 mg)• serum potassium >5.5 mmol/L (predicts >100% mortality without treatment)• serum digoxin level >15 nmol/L (>12 ng/mL).Any hyperkalaemia is significant in acute digoxin toxicity and is an indication for the use of digoxin immune Fab as a temporising measure. Temporising options for hyperkalaemia treatment, read more..

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    AnSWERS337Severe CCB toxicity may lead to hyperglycaemia because a reduced release of insulin from pancreatic islet cells.actionGoTo:362,15,3824. Answer: AIsolated overdose with a beta-blocker, except sotalol and propranolol, causes minimal or no toxicity in most healthy adults. The risk of toxicity is increased in patients with underlying cardiovascular disease, those who take other potential cardiotoxic drugs and in the elderly.Overdoses with sotalol and propranolol are serious and potentially read more..

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    338CHAPTER19ToxiCologyAndToxinologyIntermittent boluses of high concentrated glucose (e.g. 50% glucose 50 mL) with a background 5–10% dextrose infusion to maintain euglycaemia is not the best way to manage hypoglycaemia in these patients. Intermittent glucose boluses stimulate endogenous insulin secretion and therefore potentially cause rebound actionGoTo:363,hypoglycaemia.41,4228. Answer: CThe majority of patients remain asymptomatic following an acute overdose of thyroxine. Symptoms are not read more..

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    AnSWERS33932. Answer: BWidely used household products contain corrosive substances that may result in injury to young children because of poor storage practices. Among those household substances, oven and drain cleaners (potassium hydroxide and sodium hydroxide) have high potential to cause mucosal burns. Household bleaches are relatively safe and generally cause minor injury. Dishwashing powders and tablets are highly alkaline and cause immediate burns. This may be due to the prolonged surface read more..

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    340CHAPTER19ToxiCologyAndToxinology35. Answer: CThe list of drugs that could cause severe cardiotoxicity leading to cardiac arrest is not exhaustive. Cardiac sodium, potassium and calcium channel blockers and beta-blockers are among the major groups of drugs that cause cardiac arrest in a poisoned patient. Advanced life support guidelines applied to a poisoned patient who is in a cardiac arrest are similar to that applied to other patients who are in cardiac arrest. Treatment with specific read more..

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    AnSWERS34138. Answer: AAcquired methaemoglobinaemia is a well-recognised toxicity syndrome secondary to accidental or deliberate exposure to drugs and toxins that act as oxidisers of iron in the haem moiety of haemoglobin from the ferrous (Fe2+) to ferric (Fe3+) form. Generally local anaesthetics, nitrates and nitrites, dapsone, rifampicin and sulfa drugs and some Asian food additives are implicated. Methaemoglobinaemia can be caused by recreational exposure to amyl nitrite and other alkyl read more..

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    342CHAPTER19ToxiCologyAndToxinology41. Answer: BBrown snake venom contains potent procoagulants, cardiotoxins and presynaptic neurotoxins. VICC is the hallmark of brown snake envenoming and can cause death due to uncontrolled haemorrhage. The onset is usually early after the bite and presents as bleeding from the gums and venepuncture sites, as well as intracerebral haemorrhage. The INR and D-dimer are elevated in VICC, whereas fibrinogen is consumed and its levels are almost undetectable.In read more..

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    AnSWERS343administered. The antivenom infusion may be recommenced cautiously when the clinical manifestations are controlled. Rarely, it might be necessary to administer an ongoing adrenaline infusion to complete the antivenom actionGoTo:364,administration.74,7545. Answer: APatients often give a history of witnessing a painful bite by a big black spider with large fangs. Local erythema and swelling are not features of funnel-web spider bite. Funnel-web spider bite is potentially life read more..

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    344CHAPTER19ToxiCologyAndToxinologyMost symptoms resolve quickly and in the majority this syndrome is not life threatening. The minority of cases develop life-threatening symptoms possibly secondary to uncontrolled hypertension:• severe pain resistant to opioids• acute pulmonary oedema• transient cardiomyopathy• cardiogenic shock• intracerebral haemorrhage.There is no strong evidence basis for current treatments of this syndrome. Vinegar is the recommended first aid. Intravenous read more..

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    REFEREnCES345The syndrome can be confused with fish allergy or anaphylactic reaction. However, the treatment is similar to treatment of those conditions (i.e. with antihistamines, adrenaline, bronchodilators and intravenous fluids).actionGoTo:364,84–85References1. SnookC,HandelD.Principlesofeliminationenhancement.In:HadadandWinchester’sclinicalmanagementofpoisoningandoverdose.4thed.Philadelphia:SaundersElsevier2007.p.44–53.2. read more..

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    346CHAPTER19ToxiCologyAndToxinology33. MurrayL,DalyF,LittleM,etal.Toxicologyhandbook.2nded.N-acetylcysteine.Sydney:ChurchillLivingstoneElsevier;2011.p.403–6.34. MinnsA,CantrellF,ClarkR.Deathduetoacutesalicylateintoxicationdespitedialysis.JEmergMed2011;40(5):515–7.35. MurrayL,DalyF,LittleM,etal.Toxicologyhandbook.2nded.Salicylates.Sydney:ChurchillLivingstoneElsevier;2011.p.336–40.36. read more..

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    REFEREnCES34771. MurrayL,DalyF,LittleM,etal.Toxicologyhandbook.2nded.Tigersnake.Sydney:ChurchillLivingstoneElsevier;2011.p.439–42.72. MurrayL,DalyF,LittleM,etal.Toxicologyhandbook.2nded.Taipan.Sydney:ChurchillLivingstoneElsevier;2011.p.442–5.73. MurrayL,DalyF,LittleM,etal.Toxicologyhandbook.2nded.Approachtosnakebite.Sydney:ChurchillLivingstoneElsevier;2011.p.36–43.74. MurrayL,DalyF,LittleM,etal.Toxicologyhandbook.2nded.Redbackspider.Sydney:ChurchillLivingstoneElsevier;2011.p.459–60.75. read more..

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    348CHAPTER20EnviRonmEnTAlEmERgEnCiEs1. Answer: BCooling is the cornerstone of good outcomes in heat-injured patients and must be done in an appropriate manner. Studies show that the degree of organ damage correlates with the degree and duration of temperature elevation above 40°C, therefore a reasonable clinical goal is to rapidly reduce the temperature to below 40°C within 30 minutes to an hour after the start of therapy. Cooling techniques should be stopped when the temperature reaches read more..

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    AnsWERs349(AGE and DCS) until proven otherwise. Distinguishing AGE from decompression sickness is difficult but differentiation between these disorders before recompression is unnecessary since recompression in a hyperbaric chamber is indicated for both. ‘Nitrogen narcosis’ is due to the anaesthetic effect of nitrogen dissolved in lipid membranes; symptoms are similar to those of alcohol intoxication and occur at depth. It is immediately reversible on ascent.The optimal position to manage read more..

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    350CHAPTER20EnviRonmEnTAlEmERgEnCiEsare absolutely reliable with respect to death or survival. Furthermore, there are no established rules or consistent algorithms regarding length of resuscitation and therefore the decision to terminate resuscitation is an individual decision made on a case-by-case basis.The Conn and Modell classification (1980) is a useful classification of the mental status after drowning: category A – awake; category B – conscious but obtunded; and category C – read more..

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    AnsWERs351vasospasm have been described primarily in the context of electrical injury due to lightning. Keraunoparalysis is characterised by flaccidity and complete loss of sensation of the affected limbs. Peripheral pulses are generally impalpable and the affected limb takes on a mottled, pale, blue appearance. Keraunoparalysis is self-limiting and resolves within 1–6 hours. If it does not resolve in a few hours, other causes should be considered.actionGoTo:369,15–189. Answer: AAMS is a read more..

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    352CHAPTER20EnviRonmEnTAlEmERgEnCiEsabominal pain due to damage of the intestinal mucosal barrier with massive fluid losses resulting in profound volume loss, electrolyte disturbances, gastrointestinal bleeding and fulminant enterocolitis• Cardiovascular/CNS syndrome (dose >20–30 Gy)• prodrome within minutes with no latent phase• leakage of fluid into tissue causing refractory hypotension and neurological symptoms4. Recovery or actionGoTo:369,death.22–24References1. read more..

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    ANSWERS3531. Answer: BThe MSE begins from the moment the clinician first observes a patient and not at the start of the formal interview. The observations of mental state are important and often more revealing than a small sample of behaviour observed during the interview. The main parts of MSE are:• behaviour• speech• mood• affect• formal thought content• perceptual ideation• cognition• insight and judgement.Under the category of speech, suicidal and homicidal ideation and read more..

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    354CHAPTER21PSyCHiATRiCEmERgENCiESDepression is common in women, in patients with chronic medical conditions, patients reporting insomnia, and in patients who have experienced stressful life events such as loss of a spouse, functional decline or social isolation. These patients often present with other problems including worsening of their existing medical illnesses. In a scenario such as that described, it is important to differentiate depression from grief. Depressive symptoms last longer than read more..

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    ANSWERS355Patients should be assessed in a sympathetic but direct manner using ‘a graduated approach’. Assessing or estimating the suicidal risk of a patient is one of the most challenging clinical judgement situations. All information about risk factors gathered during interview with the patient and other sources should be applied to the patient’s clinical presentation and its severity. The risk factors are generally cumulative and worsen the overall risk; however, they should be read more..

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    356CHAPTER21PSyCHiATRiCEmERgENCiES7. Answer: DBPD is a very common presentation to the ED, with a high level of time and resource requirements in its management. These patients often have comorbid illnesses and therefore may present to the ED in a variety of presentations. Although a BPD patient occasionally presents with a psychotic illness (such as paranoid schizophrenia) other presentations are more common. Most patients with BPD (84.5%) meet criteria for diagnoses such as mood disorders, read more..

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    ANSWERS357Medical complications that should be assessed in the ED include (these can be used as physiological indications for hospital admission):• dehydration• bradycardia• cardiac arrhythmia• hypotension or postural hypotension• other cardiovascular abnormalities• hypothermia (body temperature <36.1°C)• symptomatic hypoglycaemia• hypokalaemia or hypophosphataemia• weight <75% of the expected weight• any rapid weight loss of several kilograms within a week• lack of read more..

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    358CHAPTER21PSyCHiATRiCEmERgENCiESantipsychotics such as olanzapine, risperidone, clozapine and aripiprazole can also cause this syndrome. It has a mortality rate of 10–20%. The onset of symptoms can be rapid or gradual. The development of symptoms is not dose dependent. Other symptoms include:• muscular rigidity• elevated temperature (due to muscular contraction causing heat generation and impaired temperature control)• autonomic dysfunction (tachycardia, increased BP or labile BP)• read more..

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    ANSWERS359may have disturbances to their consciousness with confusion and disorientation (a delirium syndrome). After recovery from both the psychotic and delirium syndromes these patients typically have amnesia to the whole or part of the episode.In addition to psychosis, amphetamines may induce manic or hypomanic symptoms during intoxication, and depression during withdrawal. Other issues include amphetamine-induced sleep disorder, anxiety disorder, sexual dysfunction and other psychological read more..

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    360CHAPTER21PSyCHiATRiCEmERgENCiEStextbookofpsychiatry.8thed.Philadelphia:LippincottWilliamsandWilkins;2005.p.1188–200.19. vanKammenD,MarderS.Serotonin-dopamineantagonists(atypicalorsecondgenerationantipsychotics).In:SadockB,SadockV,editors.KaplanandSadock’scomprehensivetextbookofpsychiatry.8thed.Philadelphia:LippincottWilliamsandWilkins;2005.p.2914–38.20. read more..

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    ANSWERS3611. Answer: DA neonate will lose about 10% of birth weight in the first week of life; this is a combination of initial osmotic diuresis post birth, passage of meconium, as well as initial slow introduction of breast or bottle feeding. Birth weight is usually regained at 10–14 days. General weight gain is 30 g per day or 1% of birth weight per day. Poor weight gain is an important indicator of a chronic organic process such as congenital heart disease, metabolic disease, malabsorption read more..

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    362CHAPTER22PAEdiATRiCEmERgENCiES3. Answer: BJaundice occurs in most newborn infants and is usually benign, but because of the potential toxicity of bilirubin, newborn infants must be risk stratified to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The following are risk factors for development of severe hyperbilirubinaemia and acute bilirubin encephalopathy:• Major risk factors include• predischarge TSB or TcB read more..

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    ANSWERS363Mycobacterium tuberculosis may also produce meningitis.TORCHES infections (agents that cross the placenta; Toxoplasmosis gondii, rubella, CMV, herpes, syphilis) may be asymptomatic at birth or may have mild symptoms to multisystem involvement. Clinical signs that raise suspicion of an intrauterine infection (and help distinguish these infections from acute bacterial infections that occur during labour and delivery) include intrauterine growth restriction, microcephaly/hydrocephalus, read more..

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    364CHAPTER22PAEdiATRiCEmERgENCiESCardiacCongenital: hypoplastic left heart syndrome, other structural disease, persistent pulmonary hypertension of the newborn (PPHN)Acquired: myocarditis, hypovolemic or cardiogenic shock, PPHNGastrointestinalNecrotising enterocolitisSpontaneous gastrointestinal perforationStructural abnormalitiesHaematologicNeonatal purpura fulminansImmune-mediated thrombocytopeniaImmune-mediated neutropeniaSevere anaemiaMalignancies (congenital leukaemia)Hereditary clotting read more..

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    ANSWERS365strategies (Rochester, Philadelphia and Boston criteria) have been tested to identify a set of low-risk criteria based on clinical and laboratory findings. If these criteria are met, it may allow for less aggressive treatment, withhold empirical antibiotic therapy, or allow management as an outpatient. Unlike the other studies, the Rochester criteria did not include spinal fluid analysis as a routine part of their low-risk criteria, based the attainment of urine cultures upon the read more..

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    366CHAPTER22PAEdiATRiCEmERgENCiESearly onset (<7 days) and late onset (7–90 days). Vaginal or rectal colonisation occurs in up to approximately 30% of pregnant women and is the usual source for GBS transmission to newborn infants. In the absence of maternal chemoprophylaxis, approximately 50% of infants born to colonised women acquire GBS colonisation, and 1–2% of these infants develop invasive disease.The IT ratio (immature : total neutrophil) has been in use in neonatal nurseries for read more..

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    ANSWERS36713. Answer: CDefervescence after paracetamol administration has not been shown to reliably exclude bacteremia and therefore a response to paracetamol does not predict a benign course in these children. The use of antipyretics such as ibuprofen and paracetamol are useful in lowering the temperature of the child more rapidly (compared with the child’s natural sinusoidal temperature variance), allowing for two important management points: symptomatic relief, as the child may be less read more..

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    368CHAPTER22PAEdiATRiCEmERgENCiESTABLE22.1SYmPTOmPROFiLEOFVARiOUSCONdiTiONSFeverRashAdenopathyConjunctivitisOralPeripheralOtherKD– Present in 99% of cases– >5–30 days– Unresponsive to antipyretic treatment– Usually >38.5°C– Present in 80% of cases– Polymorphous– Diffuse– Present from the start of the illness– Present in 50% of cases– Cervical– Painful– Singular– Present in 90% of cases– Nonexudative– Perilimbal sparing– Present in 90% of cases– Red read more..

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    ANSWERS369extremity changes, cervical lymphadenopathy), whereas in atypical or incomplete KD the full criteria are not met. Other findings (not included in the criteria) include sterile pyuria, arthritis (10%), reactive thrombocytosis, normocytic normochromic anemia, transaminitis, hydrops of gallbladder, hyponatremia, aseptic meningitis (which may explain severe irritability) and erythema of the Bacillus Calmette-Guérin (BCG) vaccination site (50%).This patient has signs satisfying the read more..

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    370CHAPTER22PAEdiATRiCEmERgENCiESincomplete KD, or fever >5 days who are young, should have a full lab work-up, including CRP and ESR, and one should have a low threshold to progress to urgent echocardiography to further evaluate the risk of coronary artery complications. The following steps summarise the approach to fever >5 days and suspected incomplete KD:• Establish fever >5 days with 2–3 clinical criteria for KD.• If consistent with potential KD, assess lab tests.• If CRP read more..

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    ANSWERS371criteria), and 64% had peripheral WBC counts between 5000 and 20,000 (low risk according to Boston criteria). They concluded that LPs of febrile infants should not be omitted based on the results of peripheral WBC actionGoTo:405,counts.25The common causes of bacterial meningitis in children 1 month to 12 years of age are N. meningitidis, S. pneumoniae and H. influenzae type b. Specific host defense defects due to altered immunoglobulin production in response to encapsulated pathogens read more..

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    372CHAPTER22PAEdiATRiCEmERgENCiESillnesses can cause generalised inflammation of the CNS. Relative to infections, these disorders are uncommon and include malignancy, collagen vascular syndromes and exposure to toxins.Careful examination of the CSF may indicate the specific cause with specific stains (Kinyoun carbol fuchsin for mycobacteria, India ink for fungi), cytology, antigen detection (Cryptococcus), serology (syphilis, West Nile virus, arboviruses), viral culture (enterovirus) and read more..

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    ANSWERS373disorder including failure to thrive, vomiting, abnormal development, features of malaise and previous seizures.It is rare for bacterial meningitis to be diagnosed on a routine LP after a simple febrile seizure. If the only indication for performing an LP is the seizure, meningitis will be found in <1% of patients and less than one-half of these will have bacterial meningitis. A more appropriate option would be to arrange careful observation of the child within the ED or a short read more..

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    374CHAPTER22PAEdiATRiCEmERgENCiESshould always be excluded. In this particular case, a work-up to cover the above differentials would include an urgent brain CT scan to exclude acute or acute on chronic subdural haemorrhage.This neonate needs resuscitative care with oxygen and fluid. Neonatal status epilepticus is best terminated with phenobarbitone loading as first choice, followed by benzodiazepines as second-line therapy if this fails. BP assessment in neonates is notoriously inaccurate, as read more..

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    ANSWERS375be depressed and may fail to breathe spontaneously. In the ensuing hours, they remain hypotonic or change from a hypotonic to a hypertonic state, or their tone may appear normal. Hypotonia, lethargy and decreased spontaneous movements are classic signs. Upper motor neuron (UMN) brisk tendon reflexes and hypotonia are hallmarks of this condition.Intracranial haemorrrhage is the second most common cause of neonatal seizures. Intracerebral haemorrhage is often related to prematurity, read more..

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    376CHAPTER22PAEdiATRiCEmERgENCiESpyridoxal phosphate should be administered intravenously, ideally during the performance of an EEG. The seizures abruptly cease, and the EEG normalises in the next few hours. Some cases of pyridoxine dependency do not respond dramatically to the initial bolus of IV pyridoxine. Therefore, a 6-week trial of oral pyridoxine or preferably pyridoxal phosphate is recommended for infants in whom a high index of suspicion is present.actionGoTo:406,4730. Answer: BThis read more..

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    ANSWERS377those from families of lower socioeconomic status are also at increased risk. DKA is rare in children whose insulin is administered by a responsible adult.Insulin should be commenced after fluid rehydration has commenced. Administration of intravenous fluid prior to insulin results in substantial falls in blood glucose, because the resultant increase in glomerular filtration rate (GFR) leads to increased urinary glucose excretion. The aims of fluid and sodium replacement therapy in DKA read more..

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    378CHAPTER22PAEdiATRiCEmERgENCiESand inspiratory crackles – wheezing may be associated but is not an essential feature. The upper age for bronchiolitis is limited to 12 months of age in the Australasian and English literature, whereas European and North American publications include cases up to age of 3 years – this may explain ‘bronchodilator response’ in some studies. The differential diagnosis should always be considered and include:• asthma in young children with atopy• cystic read more..

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    ANSWERS379Innocent pulmonic murmurs are also common and occur due to turbulence during ejection into the pulmonary artery. They are higher pitched, blowing, brief early systolic murmurs of grade I–II in intensity and are best detected in the second left parasternal space with the patient in the supine position.A venous hum is another common innocent murmur heard during childhood due to turbulence of blood in the jugular venous system; they have no pathologic significance and may be heard in read more..

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    380CHAPTER22PAEdiATRiCEmERgENCiESthe airway also dilates to improve airflow to the now already dilated capillary bed, ultimately improving gaseous exchange.Steroids are of no benefit in bronchiolitis. Another Cochrane review determined that systemic corticosteroids have no impact on clinical scores, admission rates, length of stay or readmission rates and should not be used routinely in the management of bronchiolitis.actionGoTo:407,84Three percent hypertonic saline may be useful. Four small read more..

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    ANSWERS38141. Answer: DWheezing is common in children with the highest incidence in preschool children. Epidemiological studies have demonstrated three different phenotypes; the majority of children will stop wheezing before the age of 3 (transient wheezers), some will wheeze beyond this age (persistent wheezers) and a small group will only start wheezing at 3 years of age (late onset wheezers). Few children continue to wheeze beyond 6 years.In infants, wheezing is often not due to asthma but read more..

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    382CHAPTER22PAEdiATRiCEmERgENCiESsuppurative lung disease, atypical pneumonia, cystic fibrosis and structural abnormalities to ensure the wheeze is not due to an organic cause. This exclusion of other causes can be done with careful history taking and good clinical examination.actionGoTo:407,71,7242. Answer: CThis girl has symptoms suggestive of asthma. She would be classified as persistent asthma due to her interval symptoms and would benefit from preventer medication. Exclusion of other causes read more..

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    ANSWERS38343. Answer: DThis child most likely has post viral cough syndrome with irritation of her upper airways, activation of cough receptors and therefore worse coughing at night (due to cold air, and lying flat with upper airway secretions causing irritation). Symptomatic management with upper airway soothing agents such as honey or warm drinks may be of benefit, although the course is usually 4–8 weeks with spontaneous resolution in time. Pneumonia is unlikely, as this child appears read more..

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    384CHAPTER22PAEdiATRiCEmERgENCiESuncommon. The WBC count is usually normal; the erythrocyte sedimentation rate tends to be elevated. Mycoplasma infection is often diagnosed clinically and treated empirically. Diagnosis may be confirmed with acute and convalescent antibody titers; however, patients may take 4–6 weeks to seroconvert, and some patients may fail to mount an immune response. Culture is not routinely available; PCR diagnosis from throat swabs is available at selected labs. read more..

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    ANSWERS385abnormalities in critically ill children with complicated pneumonia. Thoracentesis for diagnostic and therapeutic purposes is important. Although most suggestive of bacterial infection, parapneumonic effusions also occur with mycoplasmal and occasionally with viral infections. Bronchoscopy with bronchoalveolar lavage may be useful in a severely ill child. Nasopharyngeal viral cultures, antigen detection for specific viral or bacterial agents, and serum antibodies for specific agents read more..

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    386CHAPTER22PAEdiATRiCEmERgENCiESTABLE22.6dEVELOPmENTALmiLESTONESAge (months)Gross motorVisual motorLanguage, social and adaptive1Raises head slightly from prone positionBirth: visually fixes1 month: has tight grasp, follows to midlineAlerts to soundRegards face2Holds head in midline, lifts chest off tableFollows object past midlineSmiles socially (after being stroked or talked to)Recognises parent3Supports on forearms in prone position, holds head up steadilyHolds hands open at rest, follows in read more..

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    ANSWERS387TABLE22.7NORmALPAEdiATRiCViTALSigNSFORAgEAge (years)Respiratory rate (breaths/minute)Heart rate (beats per minute)<130–60100–1601–224–4090–1502–522–3480–1406–1218–3070–120>1212–1660–100Adapted from Dieckmann R, Brownstein D, Gausche-Hill M, editors. Pediatric education for prehospital professionals. Sudbury: Mass, Jones & Bartlett, American Academy of Pediatrics, 2000:43–45.assessment, that is, normalisation of HR when apyrexial would confirm the read more..

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    388CHAPTER22PAEdiATRiCEmERgENCiESReferences1. ModyAP,SilvermanBK.Problemsintheearlyneonatalperiod.In:FleisherGR,LudwigS,editors.Textbookofpediatricemergencymedicine.6thed.Philadelphia:LippincottWilliams&Wilkins;2011.p.902–1010.2. CarloWA.Prematurityandintrauterinegrowthrestriction.In:KliegmanRM,BehrmanRE,JensonHB,etal,editors.Nelsontextbookofpediatrics.19thedn.Philadelphia:SaundersElsevier;2011.p.552–63.3. read more..

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    REFERENCES389theYoung,AmericanHeartAssociation.Circulation2004;110:2747–71.32. DemmlerGJ.Adenoviruses.In:LongS,PickeringLK,ProberCG,editors.Long:principlesandpracticeofpediatricinfectiousdiseases.3rded.Philadelphia:ChurchillLivingstone;2008.p.1052–5.33. Jordan-VillegasA,ChangML,RamiloO,etal.ConcomitantrespiratoryviralinfectionsinchildrenwithKawasakidisease.PediatrInfectDisJ2010;29:770.34. QuigleyR.Diagnosisofurinarytractinfectionsinchildren.CurrOpinPediatr2009;21(2):194–8.35. read more..

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    390CHAPTER22PAEdiATRiCEmERgENCiES64. KuzikBA,Al-QadhiSA,KentS,etal.Nebulizedhypertonicsalineinthetreatmentofviralbronchiolitisininfants.JPediatr2007;151(3):266–70,270e1.65. SarrellEM,TalG,WitzlingM,etal.Nebulized3%hypertonicsalinesolutiontreatmentinambulatorychildrenwithviralbronchiolitisdecreasessymptoms.Chest2002;122:2015–20.66. KugelmanA.Intravenousfluidsversusnaso/orogastric-tubefeedinginhospitalizedinfantswithbronchiolitis.Israel:Trial.BnaiZionMedicalCenter,MinistryofHealth;2010.67. read more..

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    ANSWERS3911. Answer: BDisaster planning is organised on an integrated approach to deal with any circumstance (all-hazard, all-agency). However, standard codes are nationally applied to a number of specific circumstances – red, (fire), blue (cardiac arrest), black (personal injury threat), yellow (internal emergency), brown (external emergency), purple (bomb threat) and orange (evacuation).Australian disaster planning is coordinated under aegis of Emergency Management Australia (EMA), a branch read more..

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    392CHAPTER23DiSASTERMANAgEMENTSurge capacity includes four elements (4 Ss):• staff• stuff (equipment)• structure (physical and management)• space.Available bed spaces are only one element of a hospital’s ability to deal with a surge. All patients arriving during the management of an incident should be tracked using the same (dedicated) documentation system, since they involve deploying the same ED and hospital resources. ED staff are best utilised within the ED – it is possible that read more..

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    ANSWERS3937. Answer: CSmallpox virus spreads by person-to-person droplet transmission. Infection via pharynx results in widespread centripetal vesicular skin rash, high fever and severe abdominal pain. Diagnosis is made by electron microscopy findings in association with clinical features. The discovery of a single suspected case should be treated as an international health emergency.Anthrax is a naturally occurring aerobic, gram-positive bacillus which can cause respiratory, cutaneous or read more..

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    394CHAPTER23DiSASTERMANAgEMENTpatients should be taken to different treatment areas, and in which order.• All ambulant patients are prioritised P3, regardless of injury.• Patients with non-patent airways must be considered dead, in order to optimise resources where they can be of benefit.• Patients with respiratory rate <10 or >29 are P1 (top priority), as are those with a cap refill >2s or pulse >120.• Everyone else is assigned a P2.All patients will then be reassessed at read more..

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    ANSWERS3951. Answer: CACEM provides recommendations on the minimum size and number of treatment areas in the configuration of an ED in Australia and New Zealand. These must be considered in relation to the projected activity, casemix and population served by an individual department.Ambulatory and ambulance entrances should be separate, for reasons of security, control of patient flow and traffic safety. Paediatric areas require adequate space to accommodate not only the patient, but also adult read more..

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    396CHAPTER24EdMANAgEMENTANdMEdiColEgAliSSuES• implement local clinical guidelines and protocols.However, additional costs to consider include not only introduction but maintenance of both software and hardware, training of staff to maintain consistent practice, and ongoing development to ensure it supports expansion and changing practice within the department. Procedures to support data security, data integrity and back-up during power loss are actionGoTo:421,required.25. Answer: DEffective read more..

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    ANSWERS397other departments should be redirected to the appropriate manager.While many staff may be distressed when informed of a complaint, these consistently occur in relation to a few areas – most commonly, in communication with or attitude of staff, access to services, and inadequate/incorrect treatment. The majority of treatment complaints relate to issues that are simple to address by implementing CQI systems, such as missed fractures or inadequate analgesia.Complaints should be read more..

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    398CHAPTER24EdMANAgEMENTANdMEdiColEgAliSSuESPeople who are aggressive may provoke automatically negative and forceful responses. However, a number of stresses may be acting on such an individual: unfamiliarity with the environment and with the behaviour expected; lack of information; and anxiety over his sibling’s condition (there is also the question of mechanism of injury yet to be established). Providing him with clear, current information may relieve these anxieties and reduce his read more..

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    ANSWERS399waiting times per ATS triage category, access block, ambulance bypass – established internally or by external authorities such as ACEM or the Australian Council on Healthcare Standards (ACHS). Morbidity and mortality rates, written complaint rates and patient ‘Did Not Wait’ rates also constitute measures of quality.actionGoTo:421,1213. Answer: BCQI begins with the concept that things can be done better than they are being done now. Improving quality within an ED requires several read more..

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    400CHAPTER24EdMANAgEMENTANdMEdiColEgAliSSuESblock runs the risk of spreading the block to this area and impairing the ability of the unit to function. Patients being transferred to the unit should have a defined condition or management protocol, including a specific end point at which the patient is to be admitted or discharged. Primary responsibility for patients within the ED remains with the emergency clinician responsible for the department until they are physically transferred to another read more..

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    ANSWERS401Factors specific to the ED increase the possibility of medical error – relating to staff, clinical situation, physical environment (including overcrowding), and complex interactions with multiple other systems.Areas of error, rather than being unpredictable, occur at points found repeatedly across EDs:• patient identification errors• triage-related errors• hospital-acquired infections• delays and misinterpretation of radiology and pathology tests• medication errors• read more..

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    402CHAPTER24EdMANAgEMENTANdMEdiColEgAliSSuESThe patient’s judgement as to what is in her own best interest may differ from that of the treating team but constitute a valid viewpoint. When in doubt, enlist another staff member or senior, and document the decision-making process clearly. Where there is disagreement, discuss with the hospital legal advisors at an early actionGoTo:421,stage.2423. Answer: AWhile hospital staff have a duty to provide each patient with the best clinical care and read more..

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    ANSWERS403vestibulocochlear, oculocephalic and cough. There should also be absent responses to pain, atropine injection, and absent respiratory effort at PCO2 over 60 mmHg with adequate oxygenation. In consideration for organ transplant, examinations should be carried out by at least two experienced doctors, neither of whom are on the transplant team, one of whom has not been directly involved with the patient’s current actionGoTo:422,care.2728. Answer: CRequirements for coronial notification read more..

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    404CHAPTER24EdMANAgEMENTANdMEdiColEgAliSSuESbeing a possible issue with discipline or unacceptable values. Chronic low-grade stress – burnout – may be difficult to recognise initially, but changes in behaviour, loss of empathy, and dependence on drugs and alcohol are features of concern. Suspension may remove the doctor from a situation of risk while further assessment is made; however, it may also be seen as ‘proof’ of wrong-doing.When a health-related notification is received by AHPRA, read more..

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    REFERENCES40526. KnoxI,CramptonR.Sexualassault.In:CameronP,JelinekG,KellyA,etal,editors.Textbookofadultemergencymedicine.3rded.Sydney:ChurchillLivingstoneElsevier;2009.p.658–64.27. DilleyS,DunnR.Neurologicalassessment.In:DunnR,etal,editors.Theemergencymedicinemanual.5thed.Tennyson:VenomPublishing;2010.p.605–29.28. DunnR,BrookesJ.Dealingwithspecialsituations.In:DunnR,etal,editors.Theemergencymedicinemanual.5thed.Tennyson:VenomPublishing;2010.p.208–27.29. read more..

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    INDEX407Page numbers followed by ‘t’ indicate tables, and ‘b’ indicate boxes.AA-a gradientactionGoTo:70,, 53actionGoTo:255,, 238AAA see abdominal aortic aneurysmAACG see acute angle closure glaucomaabdominal aortic aneurysm (AAA)rupture risk actionGoTo:88,and, actionGoTo:301,71, 284ultrasound actionGoTo:88,and, actionGoTo:300,71, 283abdominal painactionGoTo:87,acute, actionGoTo:299,70, 282in actionGoTo:91,children, 74actionGoTo:311,, 294–295in female of reproductive actionGoTo:102,age, read more..

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    408INDEXHUS andactionGoTo:219,, 202pneumonia regime ofactionGoTo:61,, 44actionGoTo:236,, 219pyelonephritis regime ofactionGoTo:328,, 311anticholinergic syndromeactionGoTo:104,, 87actionGoTo:350,, 333anticoagulation actionGoTo:58,therapy, actionGoTo:226,41, 209anti-convulsive therapyactionGoTo:117,, 100actionGoTo:391,, 374, 374tanti-D actionGoTo:99,prophylaxis, actionGoTo:336,82–83, 319–320antidepressant toxicity, major tricyclicactionGoTo:104,, 87actionGoTo:350,, 333anti-hepatitis A virus read more..

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    INDEX409box actionGoTo:108,jellyfish, 91actionGoTo:360,, 343Irukandji syndrome andactionGoTo:108,, 91actionGoTo:360,, 343–344sting actionGoTo:360,features, 343actionGoTo:360,treatment, 343Boyle’s actionGoTo:109,law, actionGoTo:366,92, 349BPD see borderline personality disorderBPPV see benign paroxysmal positional vertigobrain actionGoTo:127,death, actionGoTo:419,110, 402–403breastactionGoTo:59,carcinoma, 42infectionactionGoTo:90,, 73actionGoTo:308,, 291–292bronchiectasisactionGoTo:36,, read more..

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    410INDEXbody temperature measurement inactionGoTo:115,, actionGoTo:383,98, 366bronchiolitis inactionGoTo:119,, 102actionGoTo:394,, 377–378treatment options inactionGoTo:119,, 102actionGoTo:396,, 379–380actionGoTo:397,, 380tbutton batteryingestionactionGoTo:91,, 74–75actionGoTo:313,, 296–297toxicityactionGoTo:106,, 89–90actionGoTo:357,, 340cardiorespiratory arrest incompression cycle actionGoTo:24,and, actionGoTo:144,7, 127paediatric arrhythmia actionGoTo:24,and, 7actionGoTo:143,, read more..

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    INDEX411consentactionGoTo:127,, 110actionGoTo:418,, 401–402continuous quality improvement actionGoTo:125,(CQI), actionGoTo:416,108, 399contraception, postcoital (emergency)actionGoTo:102,, 85actionGoTo:343,, 326progestin-only methodactionGoTo:343,, 326Yuzpe methodactionGoTo:343,, 326contrast-induced nephropathy (CIN)actionGoTo:54,, 37actionGoTo:216,, 199parenteral volume repletion andactionGoTo:216,, 199conversion disorderactionGoTo:112,, actionGoTo:374,95, 357COP, I’VE STUMBLED read more..

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    412INDEXdisseminated gonococcal infection (DGI)actionGoTo:63,, 46actionGoTo:238,, 221–222sexually active patient actionGoTo:66,and, actionGoTo:247,49, 230–231actionGoTo:87,diverticulitis, actionGoTo:298,70, 281DKA see diabetic ketoacidosisactionGoTo:139,dobutamine, 122, 122tdopamineactionGoTo:138,, actionGoTo:139,121–122, 122tDOPE actionGoTo:172,mnemonic, 155drowningactionGoTo:109,, 92actionGoTo:366,, 349–350drug skin actionGoTo:66,eruptions, actionGoTo:248,49, 231duct-dependent read more..

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    INDEX413ETCO2 see end-tidal carbon dioxideeucalyptus actionGoTo:106,oil, actionGoTo:355,89, 338evaporative actionGoTo:109,cooling, actionGoTo:365,92, 348expert actionGoTo:127,witness, actionGoTo:419,110, 402extracorporeal elimination, of toxinsactionGoTo:103,, 86actionGoTo:347,, 330eye emergenciesacid and alkali actionGoTo:94,injuries, 77actionGoTo:321,, 304answersactionGoTo:318,, 301–308dilated pupil andactionGoTo:94,, 77actionGoTo:320,, 303–304questionsactionGoTo:93,, 76–79retrobulbar read more..

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    414INDEXGraves’ actionGoTo:47,disease, actionGoTo:194,30, 177group B streptococcus (GBS)actionGoTo:114,, 97actionGoTo:378,, 361growth plate injuriesphyseal, in actionGoTo:81,children, actionGoTo:284,64, 267Salter-Harris type actionGoTo:81,I, actionGoTo:284,64, 267Guillain-Barré syndromeactionGoTo:44,, 27actionGoTo:186,, 169gynaecological emergenciesanswersactionGoTo:334,, 317–327questionsactionGoTo:99,, 82–85HH2O2 see hydrogen peroxideHACE see heralds high-altitude cerebral read more..

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    INDEX415hypercalcaemiaacute actionGoTo:196,life-threatening, 179causes actionGoTo:196,of, 179hydrocortisone andactionGoTo:196,, 179intravenous bisphosphonate andactionGoTo:196,, 179managementactionGoTo:48,, 31actionGoTo:60,, 43actionGoTo:196,, 179rehydration actionGoTo:196,and, 179signs and actionGoTo:251,symptoms, 234treatment actionGoTo:68,goals, actionGoTo:251,51, 234hyperemesis gravidarum actionGoTo:99,(HG), actionGoTo:334,82, 317hyperglycaemiaactionGoTo:48,, actionGoTo:197,31, 180, read more..

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    416INDEXlarge bowel/colonic actionGoTo:87,obstruction, actionGoTo:300,70, 283laryngeal mask airway actionGoTo:71,(LMA), actionGoTo:258,54, 241laryngospasmactionGoTo:71,, 54actionGoTo:258,, 241late-life depressionactionGoTo:111,, 94actionGoTo:370,, 353–354Le Fort fracturesactionGoTo:271,, 254leg actionGoTo:89,pain, actionGoTo:306,72–73, 289leukaemiaactionGoTo:60,, 43actionGoTo:232,, 215lid retractionactionGoTo:47,, 30actionGoTo:193,, 176–177actionGoTo:110,lightning, actionGoTo:367,93, read more..

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    INDEX417multiple dose activated charcoal actionGoTo:103,(MDAC), actionGoTo:347,86, actionGoTo:347,330–331mushroom poisoningactionGoTo:108,, 91actionGoTo:361,, 344mycoplasma pneumoniaactionGoTo:64,, actionGoTo:242,47, 225myocardial actionGoTo:77,contusion, actionGoTo:274,60, 257–258myocardial actionGoTo:29,infarction, actionGoTo:152,12, 135, 135tcardiogenic shock andactionGoTo:30,, 13actionGoTo:154,, 137troponin assays actionGoTo:150,and, actionGoTo:151,133, 134tsee also ST elevation read more..

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    418INDEXPpacemakercodeactionGoTo:33,, 16actionGoTo:159,, 142electrical and mechanical capture actionGoTo:33,and, 16actionGoTo:159,, 142oversensing andactionGoTo:33,, 16actionGoTo:159,, 142–143paediatricsactionGoTo:24,arrhythmia, 7actionGoTo:143,, 126–127emergencyactionGoTo:378,answers, 361–387actionGoTo:114,questions, 97–104resuscitationactionGoTo:143,answers, 126–131actionGoTo:24,guidelines, 7actionGoTo:143,, 126actionGoTo:24,questions, 7–10see also children; neonatepain management, read more..

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    INDEX419PPH see postpartum haemorrhagePPI see proton pump inhibitorPPV see pulse pressure variationpreeclampsiaactionGoTo:100,, 83actionGoTo:337,, 320–321preexcitation syndromesactionGoTo:32,, 15actionGoTo:158,, 141pregnancyabruptio placentae inactionGoTo:100,, actionGoTo:339,83, 322–323antepartum haemorrhage actionGoTo:100,and, actionGoTo:340,83–84, 323anti-D prophylaxis after first actionGoTo:99,trimester, actionGoTo:336,82–83, 319–320anti-D prophylaxis in first read more..

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    420INDEXresuscitationadultactionGoTo:132,answers, 115–124actionGoTo:20,questions, 3–7paediatricactionGoTo:143,answers, 126–131actionGoTo:24,questions, 7–10resuscitative actionGoTo:23,thoracotomy, actionGoTo:77,6, actionGoTo:140,60, actionGoTo:275,123, actionGoTo:275,258retrobulbar actionGoTo:94,haematoma, actionGoTo:322,77, 305Rh D immunoglobulin actionGoTo:99,(RhIG), actionGoTo:336,82–83, 319–320actionGoTo:70,rhabdomyolysis, actionGoTo:256,53, 239aetiology actionGoTo:55,of, read more..

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    INDEX421young adult actionGoTo:75,and, actionGoTo:271,58, 254see also cervical spine injuriesspinal actionGoTo:75,shock, actionGoTo:270,58, 253–254splenic actionGoTo:78,injuries, 61actionGoTo:276,, 259–260sprain, actionGoTo:84,ankle, actionGoTo:292,67, 275radiographic assessment ofactionGoTo:84,, 67actionGoTo:292,, 275–276talar dome fracture actionGoTo:84,and, 67actionGoTo:293,, 276SSRI see selective serotonin reuptake inhibitorSSSS see Staphylococcal scalded skin syndromeSSUs see short read more..

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    422INDEXtorsades de actionGoTo:32,pointes, 15actionGoTo:157,, 140isoprenaline actionGoTo:157,and, 140poison andactionGoTo:103,, actionGoTo:349,86, 332tourniquet inflation timeactionGoTo:72,, 55actionGoTo:261,, 244toxic epidermal necrolysis (TEN)actionGoTo:66,, 49actionGoTo:246,, 229SJS actionGoTo:66,and, actionGoTo:246,49, 229toxic actionGoTo:103,ratio, actionGoTo:349,86, 332toxicologyanswersactionGoTo:347,, 330–345questionsactionGoTo:103,, 86–91actionGoTo:62,toxoplasmosis, read more..

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    INDEX423NIV andactionGoTo:20,, 3actionGoTo:39,, 22actionGoTo:132,, 115–116actionGoTo:174,, 157obesity andactionGoTo:71,, actionGoTo:258,54, 241–242ventricular fibrillation actionGoTo:21,(VF), 4actionGoTo:134,, 117–118ventricular tachycardia (VT)actionGoTo:31,, 14actionGoTo:156,, 139–140actionGoTo:31,broad-complex, actionGoTo:157,14, 140SVT actionGoTo:31,and, actionGoTo:157,14, 140ventriculoperitoneal actionGoTo:44,shunt, 27actionGoTo:186,, 169–170vertigoactionGoTo:43,, read more..

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